【摘要】 目的对手外科常见疾病诊断和手术操作的ICD编码思路进行分析。方法从某院信息系统中导出手外科2016年全年出院患者的住院信息,对其中的疾病诊断和手术操作ICD编码进行分析。结果手外科2016年全年出院患者1169人,其中659人(占56.4%)主因外伤类疾病入院;424人(占36.3%)的主要诊断编码在S60～S69之间,对疾病诊断进行ICD编目时还需要根据损伤的具体部位选择相应的亚目,一般不使用".9"的编码。871人(占74.5%)的手术操作编码范围在77.1～88.5之间。结论手外科收治患者多因外伤入院,尤其是腕和手部损伤,编码员掌握手腕部的解剖结构,通读病案特别是读懂手术记录,是提高手外科疾病诊断和手术操作编码最好的途径。更多还原

【Abstract】 Objective To analyse ICDcoding of the common disease and surgical operation for the patients discharged from hand trauma department during 2016.Methods We exported the hospitalization information of patients discharged from hand surgery during 2016 from the hospital information system. Then we analyzed the ICD coding of the common diseases and surgical operations of hand trauma department.Results Total of 1169 patients discharged from hand trauma department during 2016. More than half of the patients(56.4%, 659/1169) admitted to hospital due to trauma.The major ICDcoding of 36.3%(424/1169)patients ranged between S60-S69.ICD coding for disease diagnosis also needs to be based on the specific site of the injury. That is to say, we need to select the corresponding suborder(range from 0 to 9) of ICD coding according to the specific site of the injury. And the coding with ".9" is generally avoided. The ICD coding pf the common surgical operations(74.5%, 871/1179) ranged between 77.1-88.5.Conclusion Patients admitted to the hand trauma department in our hospital mainly due to trauma, especially thewrist and hand. Thus, it required the coders to master the anatomical structure of wrist and hand. For a better work of ICD coding, they should also read the medical records thoroughly, so they can catalog and select the main disease diagnosis and surgical operation preferably.更多还原