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目的通过分析国际疾病和手术分类编码在口腔医院使用频率,为口腔诊断编码的规范使用提供依据。方法对某院2009年-2013年出院患者的口腔疾病和手术编码的使用频度和相似度进行统计分析。结果国际疾病分类(北京临床版)中涉及口腔医学的诊断编码为937条,占总编码量的4.39%;该院5年间收治23987例患者,75%以上患者的病种集中在国际疾病分类的肿瘤(C和D)、消化系统疾病(K)、先天性畸形(Q)章节;5年间总的诊断编码量为788条,占口腔诊断编码的84.1%;该院手术编码占口腔手术编码的75.14%-98.59%之间,占总编码的5.60%-7.37%之间;80%的诊断和手术编码的相似度分别为61.58%和47.40%。结论国际疾病和手术分类在口腔医学中的使用率相对较低,建议采用国际疾病分类牙科和口腔学分册(ICD-DA)的分类规则细化口腔诊断编码,以进一步满足临床需求。
Objective To analyze the frequency of international diseases and surgical classification codes used in oral hospitals to provide the basis for the standardized use of oral diagnosis codes. Methods The frequency and similarity of oral diseases and surgical codes of discharged patients in a hospital from 2009 to 2013 were statistically analyzed. Results There were 937 diagnostic codes for stomatology in the International Classification of Diseases (Beijing Clinical Edition), accounting for 4.39% of the total code volume. In the 5 years of the hospital, 23,987 patients were admitted, and over 75% of the patients were diagnosed in the International Classification of Diseases (C and D), digestive system diseases (K) and congenital malformations (Q). The total diagnostic coding amount was 788 in 5 years, accounting for 84.1% of the oral diagnosis codes. The surgical coding accounted for 75.14% -98.59%, accounting for 5.60% -7.37% of the total code; 80% of the diagnostic and surgical codes were 61.58% and 47.40% respectively. Conclusions The international classification of diseases and surgeries is relatively low in the use of stomatology. It is advisable to refine the oral diagnostic codes using the classification rules of the International Division of Dentistry and Oral Science (ICD-DA) to further meet the clinical needs.