摘要
目的通过分析胃壁脓肿的发病机制、发病原因、病理特征和临床表现,探讨正确查找胃壁脓肿ICD-10疾病编码的思路与方法。方法查阅广州市某三甲综合医院2019年4月普外二科1例以"胃壁脓肿"为主要诊断的病例资料,分析该病的发病机制、病因、病理结果及临床表现,按照国际疾病分类的原则,灵活替换不同主导词以查找正确编码。结果在ICD-10卷三索引表中对主导词"脓肿"、"化脓"等进行查询,均未查到与之对应的编码。遵循ICD编码规则及查阅相关医学资料对胃壁脓肿进行编码分析,最终以"胃炎"为主导词,给予正确疾病分类K29.1。结论对于病因不明确又没有特异性临床表现的一类疾病,应了解其发生、发展过程,结合影像学检查、病理组织学检查等诊断依据,详细阅读病案并分析病例,积极与临床医师沟通,才能剥去外在表象探索疾病的本质,确定该病ICD-10编码。
Objective To explore the methods for ICD-10 Coding of Gastric Abscess by analyzing its pathogenesis,etiology,pathological features and clinical manifestations.Methods A case of gastric wall abscess in the general surgery department of a general hospital in Guangzhou in April 2019 was reviewed to analyze the pathogenesis,etiology,pathology and clinical manifestations of the disease.In accordance with the principles of the International Classification of Diseases,the correct code was made by flexible replacement of different leading words.Results No corresponding code was found after searching the leading words with"abscess"and"suppuration"from the index of ICD-10(Volume III).The gastric wall abscess was analyzed and coded by following the ICD coding rules and referring to relevant medical data.Finally,gastritis was taken as the leading word and the correct disease classification was given as K29.1.Conclusion As for a category of diseases with unclear etiology and no specific clinical manifestations,it’s necessary to understand their occurrence and development process,combine imaging examination,histopathological examination and other diagnostic basis,check the medical records in detail,analyze the cases,and actively communicate with clinicians,so as to find out its truth for determination of its code by the ICD-10.
作者
欧倩婷
何凯平
刘树妹
徐娟华
刘涛
马金火
张凯娜
OU Qianting;HE Kaiping;LIU Shumei;XU Juanhua;LIU Tao;MA Jinhuo;ZHANG Kaina(The First Affiliated Hospital,Guangdong Pharmaceutical University,Guangzhou 510062,China;不详)
出处
《现代医院》
2021年第2期278-281,共4页
Modern Hospitals
