摘要
目的通过回顾性分析探讨腰椎间盘突出症手术操作分类的编码。方法利用《国际疾病分类第九次临床修订本手术与操作》(ICD-9-CM-3)和《广东省医院统计病案管理系统》手术编码字典库,从手术操作的术式和路径及所用器械或材料的不同给予ICD-9-CM-3编码。结果手术操作术式和路径及所用器械或材料不同,手术操作分类的编码亦不同。结论编码员必须认真阅读病案及手术记录,熟悉手术术式和路径,才能保证手术操作分类编码的准确性。
object Discuss the coding and categories of Lumbar disc herniation operation by retrospective analysis.Methods To encode ICD-9-CM-3 in different of the surgical operations and passing surgical instruments or materials used,according to International surgical and medical operational taxonomic（ICD-9-CM-3）and Medical Records Management System Statistics of Guangdong Provincial Hospital.Results The different of Surgical operations and passing surgical instruments or materials used will lead to the different of Operative classification codes.Conclusion Coder must carefully read the medical records and surgical records,also know well the Surgical procedures and process to ensure the accuracy of Surgical operations and classification coding.
出处
《中国病案》
2010年第3期29-29,共1页
Chinese Medical Record
