脑瘫的早期诊断有助于患儿尽早康复,但相关儿科教科书并未对脑瘫早期诊断有明确表述,经认真阅读病案、查阅相关资料、与临床医生讨论,参照脑瘫国际疾病分类的编码,以期获得准确编码,旨在为病案主动服务打下坚实基础。 Early diagnosis of cerebral palsy will help children to recover as soon as possible, but the relevant pediatric textbooks did not express clearly for early diagnosis of cerebral palsy. After carefully read the medical records, access to relevant information, discussions with clinicians, refer to the coding of the International Classification of Cerebral Palsy in order to obtain Accurate coding aims to lay a solid foundation for the active service of medical records.