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目的通过分析结肠息肉的不同的组织类型,掌握其编码原则,以提高疾病分类的准确性。方法对659例病案回顾性学习分析,根据不同的病理结果,依据“疾病和有关健康问题的国际统计分类ICD-10”的分类要求进行分类。结果结肠息肉编码为K63.5的659份病案中行病理检查并做治疗或行病理检查未行治疗的共473份,占全部病例的71.78%,其中增生性息肉123例,占26%,炎性息肉229例,占48.41%,管状腺瘤、绒毛管状腺瘤、腺瘤共40例,占8.46%;其他81例,占17.12%。结论结肠息肉是临床医师经常书写的疾病诊断之一,但是编码员不能仅仅根据医师诊断而把其全部编入K63.5中,编码员应仔细阅读病案,根据病理诊断给予正确编码,如增生性息肉编码于K63.5、炎症性息肉编码于K51.4、肿瘤性息肉按良性肿瘤编码等等。
Objective To analyze the different tissue types of colon polyps and grasp the principle of coding in order to improve the accuracy of disease classification. Methods A retrospective study of 659 medical records was conducted and classified according to the different pathological results according to the classification requirements of the International Statistical Classification of Diseases and Related Health Problems ICD-10. Results A total of 473 colorectal polyps were enrolled in 659 cases with pathological examination of K63.5 and 71.78% of them did not receive any treatment or pathological examination, of which 123 cases were hyperplastic polyps, accounting for 26%. Inflammatory There were 229 cases of polyp, accounting for 48.41%, 40 cases of tubular adenoma, choriocarcinoma and adenoma, accounting for 8.46%. The other 81 cases accounted for 17.12%. Conclusions Colonic polyps are one of the frequently diagnosed diseases diagnosed by clinicians. However, the coder can not compile all of them into K63.5 according to their diagnosis. The coder should carefully read the medical records and give correct coding according to pathological diagnosis, such as proliferative Polyps were coded at K63.5, inflammatory polyps were coded at K51.4, neoplastic polyps were coded by benign tumors, and so on.