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疾病诊断名称是分类的基础。疾病分类受疾病的病因、解剖部位、临床表现、病理改变的影响,时常出现相同的诊断在不同的情况下有不同的编码。但病案首页上的信息量毕竟不能全面满足疾病分类的要求,有时仅凭病案首页的诊断很难确定疾病的编码,需要详细阅读病案,才能选择适当的编码。本文通过对几组妇产科相同的诊断进行分析,以探讨准确的编码。
The name of the disease diagnosis is the basis of the classification. Disease classification is influenced by the etiology, anatomical site, clinical manifestations, and pathological changes of the disease. The same diagnosis often occurs with different codes in different situations. However, the amount of information on the first page of the medical record cannot fully meet the requirements of disease classification. Sometimes it is difficult to determine the coding of the disease based on the diagnosis of the first page of the case. It is necessary to read the case in detail in order to select an appropriate code. This article analyzes the same diagnosis in several groups of obstetrics and gynecology to discuss the exact coding.