Ortner's综合征的ICD-10编码探讨
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摘要
Ortner's综合征系心血管疾病压迫左侧喉返神经引起左侧声带麻痹,导致声音嘶哑等症状的一组综合征。通过查阅相关资料、沟通临床医师,深入学习Ortner's综合征的病因、疾病性质等临床知识,遵循ICD-10分类原则,选择和变通主导词,最终以"麻痹-喉神经"查得Ortner's综合征编码为J38.0。同时列举几份典型病例,准确分类Ortner's综合征。罕见综合征的分类工作较为复杂,要加强学习、积极沟通临床,熟悉疾病的命名、病因和临床表现,正确选择主要诊断,为扎实推进医保DRGs付费改革提供数据支撑。
Ortner's Syndrome is a group of syndromes in which cardiovascular diseases oppress the left recurrent laryngeal nerve and cause left vocal cord paralysis, resulting in hoarseness and other symptoms. To consult relevant materials, communicate with clinicians, and study the clinical knowledge of the etiology and nature of Ortner's Syndrome in-depth, then follow the ICD-10 classification principles, select and modify the dominant words, finally obtain its coding as J38.0 with "paralysis-laryngeal nerve". Simultaneously through enumerating several typical cases to classify Ortner's Syndrome accurately. The classification of rare syndrome is much more complicated. We should strengthen learning and communicate with clinical doctors actively, so as to master the name alias, etiology and clinical manifestation of the disease,thereby select the major diagnosis correctly, ultimately to provide data support for the reform of medical insurance payment methods.
Ortner's Syndrome is a group of syndromes in which cardiovascular diseases oppress the left recurrent laryngeal nerve and cause left vocal cord paralysis, resulting in hoarseness and other symptoms. To consult relevant materials, communicate with clinicians, and study the clinical knowledge of the etiology and nature of Ortner's Syndrome in-depth, then follow the ICD-10 classification principles, select and modify the dominant words, finally obtain its coding as J38.0 with "paralysis-laryngeal nerve". Simultaneously through enumerating several typical cases to classify Ortner's Syndrome accurately. The classification of rare syndrome is much more complicated. We should strengthen learning and communicate with clinical doctors actively, so as to master the name alias, etiology and clinical manifestation of the disease,thereby select the major diagnosis correctly, ultimately to provide data support for the reform of medical insurance payment methods.
引文
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[2]金丽玲,罗仁忠,黄萍,等.电子鼻咽喉镜在小儿心脏-声带综合征诊断中的应用[J].中国耳鼻咽喉颅底外科杂志,2014,20(04):331-333.
[3]孔维佳,主编.耳鼻咽喉头颈外科学[M].第2版.北京:人民卫生出版社,2012,12:405-406.
[4]司马国旗,邓晶,戚维波,等.Ortner综合征致声音嘶哑一例[J].中华耳鼻咽喉头颈外科杂志,2014,49(12):1036-1037.
[5]范玥尧,胡新华,曹辉,等.主动脉夹层动脉瘤继发霍纳综合征一例报道[J].中国现代普通外科进展,2010,13(05):415-417.
[6]刘爱民,主编.病案信息学第2版[M].北京:人民卫生出版社,2014,8:149.
[7]王辉,祁红.臂丛神经阻滞麻醉致霍纳综合征12例临床特征及护理体会[J].西南国防医药,2018,28(03):271.
[8]国家卫生和计划生育委员会.国家卫生计生委办公厅关于印发住院病案首页数据填写质量规范(暂行)和住院病案首页数据质理管理的控制指标(2016版)的通知[S].国卫办医发[2016]24号,2016,5.