梅毒的ICD-10编码案例分析
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摘要
回顾性分析七例典型梅毒病例,阐述梅毒的ICD-10编码思路及查找方法。有症状或体征的梅毒按分期和部位编码:先天性梅毒分类于A50;后天性的一期、二期梅毒分类于A51早期梅毒,晚期梅毒分类于A52。无临床症状的潜伏梅毒编码:先天性潜伏早期分类于A50.1,先天性潜伏晚期分类于A50.6;后天性潜伏早期分类于A51.5,后天性潜伏晚期分类于A52.8。梅毒并发于妊娠、分娩和产褥期,O98.1为主要编码,可选择性附加A50-A53。新生儿梅毒分类于A50;如果仅由于母亲梅毒影响到新生儿,新生儿不显现梅毒的分类于P00.2。梅毒血清学假阳性分类于R76.2。
In this article, 7 typical cases of syphilis were analyzed retrospectively, and the ICD-10 coding and searching method of Syphilis were expounded. Syphilis with symptoms or signs was classified by stage and location: congenital syphilis was classified in A50, primary and secondary syphilis of acquired nature were classified as early syphilis in A51 and late syphilis as early syphilis in A52. Code of latent syphilis without clinical symptoms: congenital latent syphilis was classified as A50.1 in early stage and A50.6 in late stage. Early postnatal lurk was classified as A51.5, and late postnatal lurk was classified as A52.8.Syphilis is complicated by pregnancy, childbirth and puerperium, and O98.1 is the primary encoding, which can be selectively attached to a50-a53.Neonatal syphilis was classified as A50.If only the mother syphilis affects the newborn, the newborn does not show syphilis classified as P00.2.False positive serology of syphilis was classified as R76.2.
In this article, 7 typical cases of syphilis were analyzed retrospectively, and the ICD-10 coding and searching method of Syphilis were expounded. Syphilis with symptoms or signs was classified by stage and location: congenital syphilis was classified in A50, primary and secondary syphilis of acquired nature were classified as early syphilis in A51 and late syphilis as early syphilis in A52. Code of latent syphilis without clinical symptoms: congenital latent syphilis was classified as A50.1 in early stage and A50.6 in late stage. Early postnatal lurk was classified as A51.5, and late postnatal lurk was classified as A52.8.Syphilis is complicated by pregnancy, childbirth and puerperium, and O98.1 is the primary encoding, which can be selectively attached to a50-a53.Neonatal syphilis was classified as A50.If only the mother syphilis affects the newborn, the newborn does not show syphilis classified as P00.2.False positive serology of syphilis was classified as R76.2.
引文
[1]李兰娟,任红.传染病学[M].第八版.北京:人民卫生出版社,2013:259-260.
[2]董景五.疾病和有关健康问题的国际统计分类[M].第1卷.北京:人民卫生出版社,2011:105-108.
[3]董景五.疾病和有关健康问题的国际统计分类[M].第3卷.北京:人民卫生出版社,2011:664-674.
[4]赵辨.中国临床皮肤病学[M].第1版.南京:江苏科学技术出版社,2010:1794-1798.
[5]谢幸,苟文丽.妇产科学[M].第8版.北京:人民卫生出版社,2013:102-103.
[6]彭君,徐联芳,张永喜,等.艾滋病ICD-10常见编码错误案例分析[J].中国病案,2016,17(10):27+34.
[7]王秀茹.提高ICD编码准确性的探讨[J].中国病案,2015,16(8):24-25.
[2]董景五.疾病和有关健康问题的国际统计分类[M].第1卷.北京:人民卫生出版社,2011:105-108.
[3]董景五.疾病和有关健康问题的国际统计分类[M].第3卷.北京:人民卫生出版社,2011:664-674.
[4]赵辨.中国临床皮肤病学[M].第1版.南京:江苏科学技术出版社,2010:1794-1798.
[5]谢幸,苟文丽.妇产科学[M].第8版.北京:人民卫生出版社,2013:102-103.
[6]彭君,徐联芳,张永喜,等.艾滋病ICD-10常见编码错误案例分析[J].中国病案,2016,17(10):27+34.
[7]王秀茹.提高ICD编码准确性的探讨[J].中国病案,2015,16(8):24-25.