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双语推荐：ICD10

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正确掌握国际疾病分类ICD-10和手术分类ICD-9-CM-3的编码方法、提高编码准确度和专业水平,对当前医院信息管理工作越来越重要.通过系统性的继续教育培训,相关人员应熟练掌握ICD-10和ICD-9-CM-3编码规则,并不断积累相应临床医学知识,以提高自身编码水平.编码员应做到“一个基础,六个多”:以国际疾病分类和手术分类编码规则为基础;多阅读病案,多与临床医师沟通,多了解临床医学知识,多翻书检索查询ICD编码,多总结编码经验,多跟踪医学及ICD编码最新动态.
Correctly grasping the International Classification of Diseases ICD-10 and surgical classification ICD-9-CM-3 encoding method to improve coding accuracy and professional level is increasingly important to the current hospital information management.Through systematic continuing education training,the relevant personnel should be familiar with ICD-10 and ICD-9-CM-3 encoding rules,and continue to accumulate the appropriate clinical knowledge to improve their own coding levels.Coders should be "a basis,six fits",that is based on the international classification of diseases and operation classification coding rules,coders should rcad more medical records,have more communication with clinicians,understand clinical medical knowledge,do more book search query for [CD code,sum up coding experience and multiply track the latest development of medicine and ICD coding.

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目的 分析植入型心律转复除颤器(ICD)及心脏再同步除颤器(CRT-D)患者的死亡原因.方法 将2001年1月至2011年12月在浙江医院植入ICD及CRT-D的所有患者分为3组:ICD一级预防组,ICD二级预防组及CRT-D组.分析在随访过程中所有死亡患者的死亡原因.主要死亡原因设置为:心力衰竭死亡、其他心脏原因死亡、非心脏原因死亡、猝死及不知原因死亡.结果 共有289例患者植入ICD或CRT-D,ICD一级预防51例,二级预防107例,CRT-D 131例.平均随访(4.6±2.5)年,死亡54例,其中ICD一级预防有5例(9.8％)患者死亡,ICD二级预防20例(18.7％)患者死亡,CRT-D组29例(22.1％)患者死亡.10年累计所有原因病死率为18.7％.心力衰竭性死亡25例(46.3％),非心脏原因死亡19例(35.2％),有3例(5.6％)患者猝死.结论 在植入ICD或CRT-D的所有患者中,心力衰竭死亡及非心脏原因死亡是最常见的死亡原因.猝死在死亡患者中的比例较低.
Objective To analyse the causes of death in patients with implantable cardioverterdefibrillator(ICD) and cardiac resynchronization therapy defibrillator(CRT-D).Methods From Jan.2001 to Dec.2011 all patients with ICD and CRT-D in Zhejiang hospital were included.All patients were divided into three groups:primary prevention ICD group,secondary prevention ICD group,and CRT-D group.Patients who died during follow-up period were retrieved.The causes of death included heart failure,other cardiac death,non-cardiac death,sudden death,and unknown cause of death.Results A total of 289 patients were included:51 primary prevention ICD,107 secondary prevention ICD,and 131CRTD.Average follow-up period was(4.6±2.5)years.Five patients (9.8％) with primary prevention ICD,20patients (18.7 ％)with secondary prevention ICD,and 29 patients(22.1％)with CRT-D died.The 10-year cumulative incidence of all-cause mortality was 18.7％.There were 25 (46.3％) patients died from heart failure,19 (35.2％)

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目的快速、准确对因运输事故死亡病例进行编码，提高死因监测工作质量。方法归纳、整理运输事故死亡病例信息收集工作的要点。结果完整准确获取运输事故死亡病例信息，准确进行ICD-10编码。结论快速准确对运输事故损伤死亡病例进行根本死因ICD-10编码。
Objective In order to rapid and accurate code for cases of death caused by transportation accidents and improve the quality of death surveil ance. Methods Summarize the main points for the transport accident death case information col ection. Results To obtain Complete and accurate information of transportation accident deaths, and accurate ICD-10 coding for the transport accident deaths case. Conclusion Accurately and quickly ICD-10 coding by collate completely information of transport accident death.

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国际疾病分类ICD-10是一门具有一定难度和复杂性的学科.世界卫生组织（WHO）并未给予损伤中毒类疾病详尽的ICD-10编码指导,编码错误率普遍偏高.本文就我院近年遇到的药物致病病例编码进行总结分析,与同行们共同探讨其编码的准确性,以求编码标准化、规范化.
The international classification of diseases (ICD-10) is a system with certain degree of difficulty and complexity.The rate of coding errors for conditions relating to injuries and poisoning is relatively high,because the WHO does not give detailed guidance on ICD-10 coding.This paper has summarized and analyzed the coding of drug-induced diseases which occurred in our hospital in recent years.We would like to discuss the coding accuracy with our colleagues in order to obtain standardization and normalization of the coding.

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目的：探讨一种可用于对玻璃体切除手术病例进行大样本临床研究的疾病分类方法。方法对429例玻璃体切除手术连续病例的全部ICD-10编码进行分析和归类，统计方法使用描述性统计、频次分析。结果将全部玻璃体切除手术疾病分为相互独立的10类：（1）眼外伤，（2）糖尿病相关眼病，（3）眼内肿瘤，（4）非外伤性眼内炎，（5）视网膜脱离，（6）无视网膜脱离的玻璃体视网膜病变，（7）黄斑病变，（8）白内障/晶体病变，（9）青光眼，（10）其他。ICD编码的出现频次和条目数分别反映了各类疾病在玻璃体切除手术病例中的普遍性和内在病变多样性。结论基于ICD编码的手术疾病分类方法简明、合理，反映了玻璃体切除手术的疾病特征和复杂性，可有效用于对玻璃体切除手术病例的大样本临床研究。
Objective To explore a disease classification that can be used in large sample clinical study for vitrectomy.Methods All ICD-10 diagnostic codes in 429 consecutive cases of vitrectomy were analyzed and classified.Statistical methods were descriptive statistics and frequency analysis.Results All vitrectomy diseases were divided into 10 independent categories:(1)ocular trauma, (2)diabetes-related eye disease,(3)intraocular tumor,(4)non traumatic endophthalmitis,(5)retinal detachment,(6)vitreoretinopathy without retinal detachment,(7)macular disease,(8)cataract/lenticular disorders,(9)glaucoma,(10)Miscellaneous.The frequency of ICD diagnosis and number of the entries reflect respectively the universality of each category in all vitrectomy cases and the diversity of internal lesions in that category.Conclusion This ICD diagnosis code-based operative disease classification is concise and reasonable,it reflects the characteristics and complexity of disease for vitrectomy,and can be

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目的：观察肥厚型心肌病（HCM）高危患者植入埋藏式心律转复除颤器（ICD）的疗效。 　　方法：系统收集我院2004-01至2013-10期间31例植入ICD的HCM患者的临床资料并进行随访，随访包括门诊复诊、ICD程控及电话随访。根据ICD有无正确识别及治疗，分析放电的相关性。 　　结果：31例患者平均年龄（54.9±15.0）岁，病史年限（13.5±11.5）年，植入ICD前出现晕厥或晕前反应26例，经电复律或药物复律22例，心肺复苏生存者3例。有HCM家族史7例，其中一级亲属猝死3例。31例患者最大左心室壁厚度（21.0±5.2）mm，5例有左心室流出道压差现象。ICD一级预防5例，二级预防26例。31例患者平均随访时间（37.9±29.0）个月，随访期间41.9%（13/31）患者在植入ICD后平均2年（0.5年～5年）发生ICD正确治疗事件。ICD正确识别共放电63次，平均2.1次/人，5例发生超速起搏抑制治疗共64次，平均2.0次/人，发生放电事件均为二级预防患者。6.7%患者出现并发症，包括电极移位调整1例，电极感知故障1例。与无放电患者比较，有放电患者的年龄更小、左心室流出道压差及心室颤动发生率更高，复律率更高，差异有统计学意义（P0.05）。有放电患者中安装单腔ICD与安装双腔ICD的患者比例差异无统计学意义（P>0.05） 　　结论：年轻、既往有晕厥或心室颤动史的HCM患者在服用β受体阻滞剂同时更能从ICD植入中获益。
Objective: To observe the efficacy of implantable cardiac defibrillator (ICD) in the high-risk patients of hypertrophic cardiomyopathy (HCM). Methods: A total of 31 HCM patients with ICD implantation in our hospital from 2004-01 to 2013-10 were enrolled. The follow-up study included the hospital records, clinical visit and telephonic interview. Based on identification and treatment, the relevant ICD shocks were analyzed. Results: The patients’ mean age was at (54.9 ± 15) years and the history of disease was at (13.5 ± 11.5) years. There were 26 cases suffered from syncope or pre-syncope before ICD implantation and 22 cases had the cardio-version by electrical treatment or medication including 3 survivors from cardiac arrest. There were 7 patients with family history of HCM, 3 had sudden cardiac death in their first-degree relatives. The maximum left veutricalar wall thickness of 31 patients was at (21.0 ± 5.2) mm and 5 with left ventricular outflow obstruction. There were

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目的探讨胎儿宫内窘迫的诊断和如何正确编写ICD-10编码。方法回顾性分析我院2010年1月至2013年12月收治的157例胎儿宫内窘迫的患者的病例。结果医生在病案首页上诊断就写胎儿宫内窘迫,没有分型和写出急慢性,编码员在此编码上错误率非常高,有编码急性的,有编码慢性的,分型也编的很乱。结论医院应加强培训,让临床医生了解有关ICD-10编码,编码人员要多学习临床业务知识,仔细阅读病案,经常与临床医生沟通,提高编码的准确性。
Objective To discuss the diagnosis and accurate ICD-10 coding of fetal distress.Methods 157 patients of fetal distress were retrospectively analyzed from January 2010 to December 2013.Results The doctor diagnosed fetal distress.There is not typing and acute and chronic.The error rate was coded very high by coders some were coded acute,some were coded chronic,the typing was coded very messy.Conclusion The clinical doctor should be strengthened training by hospital,Let them understand related ICD-10 coding,the coder study hard Clinical knowledge,read medical record carefuly and often communicate with clinician,to improve accuracy of code.

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目的：分析营口市站前区2012年居民恶性肿瘤发病情况，为肿瘤防治工作提供依据。方法将2012年恶性肿瘤病例资料录入到canrge4系统，疾病按照icd-10和icd-o-3分类，利用canrge4软件的分析功能进行统计分析。结果2012年营口市站前区恶性肿瘤发病率为369.16/10万，其中男性为418.8/10万，女性为318.8/10万。恶性肿瘤发病率除女性特有的恶性肿瘤（乳腺癌、宫颈癌）外，男性均高于女性（1.28：1），居前5位的恶性肿瘤依次为肺癌、肠癌、胃癌、乳腺癌、肝癌。结论恶性肿瘤仍然是影响居民健康的主要疾病。
Objective to analyze the malignant tumor incidence of residents in Zhanqian district of Yingkou city in 2012 to provide the basis for cancer prevention and treatment. Methods the data of malignant tumor cases in 2012 were input into CanRge4 system, and the diseases were classiifed by ICD-10 and ICD-O-3. Then these data were statistically analyzed by canrge4 software.Results the incidence of malignant tumor in Zhanqian district of Yingkou city in 2012 was 369.16/100 thousand, male of 418.8/10 thousand and female of 318.8/10 thousand. in addition to the feminine malignant tumor (breast cancer, cervical cancer), the incidence of malignant tumors in men was much higher than that in women (1.28:1). and the incidence of the top ifve malignant tumors was lung cancer, colon cancer, gastric cancer, breast cancer, liver cancer.

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目的：通过分析ICD-10中未特指编码的使用情况，寻找减少未特指编码误用的对策，提高编码准确率。方法总结ICD-10中所有未特指编码，对烟台某医院7230份病案的主要诊断重新进行编码，对未特指编码出现的情况进行统计汇总与分析。结果7230份病案中有2134份病案（29.5%）应用了未特指编码，其中1059份（14.6%）病案属于错误使用。结论未特指编码在病案中的误用情况比较严重，编码员除了提高自身编码水平外，还应对临床医师进行简单的编码知识培训，规范诊断名称书写，并加强编码员与临床医师的互动与交流，以减少未特指编码的使用。
Objective To explorer the problems of misuse coding of unspecified in ICD-10,analyze its reasons and search for ways to improve the coding accuracy.Methods Summarizes all unspecified codes in the ICD - 10,recode the main diagnosis of the 7230 medical records,summarize and analyze the unspecified codes.Results There are 2134 unspecified coding,accounting for 29.5%; Among them,1059 unspecified coding misused,accounting for 14.6%.Conclusion It can be seen that the misuse of unspecified coding is serious.Coders in addition to improve the level of their own,also deal with coding knowledge training for clinicians,strengthen their communication.Through these ways,the misuse rate of unspecified coding will be reduced.

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目的了解铜山区近年来恶性肿瘤发病的发展趋势和人群的分布特点，为今后有针对性开展干预提供依据。方法将2012年恶性肿瘤新发病例的资料录入到徐州市肿瘤网络报告系统中，疾病按照ICD-10分类，采用SPSS软件进行统计学分析。结果居前五位的恶性肿瘤依次为肺癌、肝癌、胃癌、乳腺癌、食管癌，发病率依次为33.35/10万、18.37/10万、13.25/10万、11.59/10万、9.03/10万，男性恶性肿瘤发病率前五位为肺癌、肝癌、胃癌、食管癌、肠癌；女性恶性肿瘤发病率前五位为肺癌、乳腺癌、肝癌、胃癌、食管癌。结论恶性肿瘤是影响居民健康和死亡的主要疾病，尤以肺癌为例。
Objective To understand the development trend and population distribution of cancer incidence in recent years in Tongshan zone. Methods The new cases of malignant tumors of information in 2012 were input to direct reporting system of the provincial chronic disease network, and classified according to ICD-10 data was analyzed using SPSS software. Results The top five of the cancers were lung cancer, live cancer, ,stomach cancer, breast cancer, esophageal cancer ,the order of the incidence were 33.35/10万、18.37/10万、13.25/10万、11.59/10万、9.03/10万,;the top five of cancer incidence in male were lung cancer, live cancer, stomach cancer , esophageal cancer, colon cancer;in female were lung cancer, breast cancer ,live cancer, stomach cancer, esophageal cancer. Conclusion Cancer mainly affects the health and death of residents in Tongshan zone .

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