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目的解决ICD-10疾病分类中先天畸形未收录的疾病名称和临床诊断无对应编码的问题。方法汇总天津市儿童医院1998年1月～2008年1月诊治的所有先天畸形疾病诊断和临床需求1 043条,按照ICD-10疾病分类思想、分类原则和编码查找方法,应用扩展码编码具体操作程序确定对应编码。结果研究解决的编码分为3种:可确定编码、新增扩展码、补充扩展码,建立了先天畸形疾病编码和扩展编码字典库。结论完善先天畸形疾病分类中医学信息代码的规范模式,可减少误码率,规范临床诊断,有利于病历档案信息资源的开发与利用。
Objective To solve the problem that the names of the diseases that are not included in the congenital malformations of ICD-10 classification and the codes of no corresponding clinical diagnosis. Methods A total of 1 043 cases of all congenital malformations diagnosed and clinically diagnosed and treated by Children’s Hospital of Tianjin from January 1998 to January 2008 were summarized. According to the idea of ICD-10 disease classification, classification principle and coding search method, Program to determine the corresponding code. The results of research to solve the code is divided into three kinds: to determine the code, add the expansion code, add the expansion code, the establishment of a congenital anomalous disease coding and extended coding dictionary. Conclusions Improving the normative mode of Chinese medical information code in congenital anomalous disease classification can reduce bit error rate and standardize clinical diagnosis, which is beneficial to the development and utilization of medical record file information resources.