产科疾病编码常见问题分析.pdfVIP

.30. 《中国病案 2015 年第 16 卷第 1 期 ·疾病与手术分类· 产科疾病编码常见问题分析 100026 北京市 首都医科大学附属北京妇产医院病案科赵会林侯东敏 摘要 通过列举具体疾病，分析产科疾病编码中常见的三类问题，包括出现在孕产期不同时期的同一 疾病名称，其疾病诊断命名和疾病编码不同;引发同一种疾病状态的致病因素很多，在产科疾病编码过程 中必须要具体区分引发疾病产生的具体原因;某些疾病临床表现近似，诊断编码归类时容易混淆。初步探 讨了产科疾病编码的一些特点，分析产生编码错误的原因并且提出了减少编码错误的措施，希望能够减少 在产科疾病编码过程中出现类似错误，提高产科疾病编码的正确率。 关键词 产科疾病;编码;常见问题 Analysis on the Common Problems Existing in the Coding of Obstetric Diseases Zhao Huilin, Hou Dongmin, Department of Medical Records, Beijing Obstetrics and Gynecology Hospital Affiliated to Capital Medical University, Beijing 100026, China Abstract To analyze the common three kinds of problems existing in the coding of obstetric diseases by listing the specific diseases, which included the name and the disease coding of the same diseases were different when they appeared in different periods of pregnancy; the pathogenic factors of the same kinds of diseases were various, so we must distinguish the specific reasons of the diseases in the process of obstetric diseases coding. The diagnosis and disease coding were confusing because of their similar clinical manifestations. We conducted a preliminary investigation on the features of obstetric diseases coding, and also analyzed the causes of those mistakes as well as put forward countermeasures to reduce the occurrence of the mistakes. Therefore, we could hope to decrease the occuπence of similar mistakes and improve the accuracy of the coding of obstetric diseases. Key words Obstetric diseases; Coding; Common problems 在孕产期的整个过程中，孕产妇和胎儿的生理 有高血压肾脏病在娃振、分娩和产褥期，编码为 变化是非常复杂的。整个孕产期包括从卵子受精开 010.2 。如果孕产妇娃振前的高血压未明确诊断是 始，到婴儿成功娩出，孕产妇除乳腺外的全身各个 原发性或继发性高血压，将其归类于原有的未特指 器官恢复或接近正常未孕状态。整个孕产期可以分 的高血压并发于娃振、分娩和产褥期，编码为 为兰个阶段，即娃振期、分娩期和产褥期。在这三