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目的探讨橡皮泡痣综合征、毛囊闭锁三联症、普杰综合征、Megie’s病4例少见疾病的ICD-10的编码。方法通过对4例少见疾病相关资料的学习,按照国际疾病地分类原则逐一给予编码。结果对于少见疑难疾病的编码一般都不能直接在ICD-10中直接找到,必须根据疾病的主要病因、病理、临床表现和解剖部位等特征,灵活变换主导词查找编码。结论为保证一些少见疾病编码的准确性,除了加强国际疾病分类的专业知识和技能外,更要具有高度的责任心,仔细阅读病案,向临床医师及经验丰富的编码员请教,查找相关的医学书籍和文献。
Objective To investigate the coding of ICD-10 in 4 cases of synovial nevus syndrome, follicular atresia triage, Pugh syndrome and Megie’s disease. Methods Four cases of rare disease-related information learning, in accordance with the principles of the classification of the international disease one by one to give coding. Results The coding of rare and difficult diseases can not be found directly in ICD-10 directly. The dominant words should be flexibly changed according to the main etiology, pathology, clinical manifestations and anatomic features of the disease. Conclusion In order to ensure the accuracy of some rare disease codes, apart from strengthening the professional knowledge and skills of international disease classification, we should also have a high sense of responsibility, read the medical records carefully, consult clinicians and experienced coders, and find relevant medical Books and literature.