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[1]韩璐.儿童恶性肿瘤病案首页主要诊断选择及ICD-10编码分类的案例分析[J].中国卫生质量管理,2024,31(08):38-40.[doi:10.13912/j.cnki.chqm.2024.31.8.08]
　HAN Lu.Primary Diagnosis Selection and Case Analysis of ICD-10 Coding Classification in Home Page of Medical Records of Pediatric Malignant Tumors[J].Chinese Health Quality Management,2024,31(08):38-40.[doi:10.13912/j.cnki.chqm.2024.31.8.08]

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儿童恶性肿瘤病案首页主要诊断选择及ICD-10编码分类的案例分析

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 第31卷期数: 2024年08期页码: 38-40 栏目: 医疗质量出版日期: 2024-08-15

Title:: Primary Diagnosis Selection and Case Analysis of ICD-10 Coding Classification in Home Page of Medical Records of Pediatric Malignant Tumors

作者:: 韩璐; 深圳市儿童医院

Author(s):: HAN Lu; Shenzhen Children’s Hospital

关键词:: 儿童; 恶性肿瘤; 病案首页; 主要诊断; ICD-10编码

Keywords:: Children; Malignant Tumor; Home Page of Medical Records; Principal Diagnosis; ICD-10 Code

分类号:: R197.5；R73

DOI:: 10.13912/j.cnki.chqm.2024.31.8.08

文献标志码:: A

摘要:: 目的为恶性肿瘤患儿病案首页主要诊断选择提供参考。方法结合主要诊断的选择总则以及恶性肿瘤主要诊断的选择原则，对恶性肿瘤患儿的主要住院目的和治疗方式进行分类，探讨不同住院目的及不同治疗方式下的病案首页主要诊断选择及ICD-10编码分类。结果患儿首次就医，主要对原发恶性肿瘤或继发恶性肿瘤进行治疗，分别选择原发或继发恶性肿瘤作为主要诊断。患儿非首次就医：主要来院化疗，选择不同治疗阶段对应的化疗诊断作为主要诊断；主要来院行造血干细胞移植，选择原发恶性肿瘤作为主要诊断；主要来院行骨穿或腰穿评估，选择相应化疗后或免疫治疗后的随诊检查作为主要诊断；主要来院输血小板、红细胞或升白细胞，选择化疗后骨髓抑制作为主要诊断；主要来院输注单抗，选择恶性肿瘤免疫治疗作为主要诊断；主要来院输注NK细胞或间充质干细胞，选择细胞治疗作为主要诊断；主要对并发症治疗，选择相应治疗的并发症作为主要诊断；患儿治疗期间死亡，选择原发恶性肿瘤作为主要诊断。结论在选择主要诊断时，应兼顾住院目的和与主要治疗方式的一致性，以实现更精准的DRG分组。

Abstract:: ObjectiveTo provide a reference for the selection of the principal diagnosis in the home page of medical records of pediatric malignant tumors.MethodsCombined with the general principles of the selection of major diagnosis and the selection principles of major diagnosis of malignant tumors, the main hospitalization purposes and treatment methods of children with malignant tumors were classified, and the selection of major diagnosis and ICD-10 coding of the home page of medical records under different hospitalization purposes and different treatment methods were discussed.ResultsFor the first admission, the primary malignant tumor or secondary malignant tumor was mainly treated, and the primary or secondary malignant tumor was selected as the primary diagnosis. Children with non-first admission and mainly for chemotherapy, the chemotherapy diagnosis was selected corresponding to different treatment stages as the primary diagnosis. For the admission purpose of hematopoietic stem cell transplantation, and primary malignant tumor was selected as the primary diagnosis. For admission for bone puncture or lumbar puncture evaluation, the follow-up examination after corresponding chemotherapy or immunotherapy was selected as the primary diagnosis. For children with platelet, red blood cell or leukocyte transfusion, myelosuppression after chemotherapy was chosen as the primary diagnosis. The admission for infusion of monoclonal antibody, malignant tumor immunotherapy was selected as the primary diagnosis. The admission for NK cells or mesenchymal stem cells injection, the cell therapy was selected as the primary diagnosis. The admission for the treatment of complications, the corresponding treatment of complications were selected as the primary diagnosis. If the patient died during treatment, the primary malignancy was chosen as the primary diagnosis.Conclusion When selecting the primary diagnosis, it is important to consider both the purpose of hospitalization and consistency with the primary treatment approach in order to achieve more accurate DRG grouping.

参考文献/References:

［1］汤静燕.中国儿童恶性实体瘤诊断与治疗现状［J］.中华儿科杂志，2017，55（10）：750-753.［2］KAATSCH P.Epidemiology of childhood cancer［J］.Cancer Treatment Reviews，2010，36（4）：277-285.［3］国家儿童肿瘤监测中心.国家儿童肿瘤监测年报（2022）［M］.北京：人民卫生出版社，2023.［4］郭超.肿瘤ICD-10编码C00-D48、Z51使用分析［J］.健康必读，2021（10）：261-262.［5］刘爱民.病案信息学［M］.北京：人民卫生出版社，2023：124-125.［6］国家卫生计生委办公厅.关于印发住院病案首页数据填写质量规范(暂行)和住院病案首页数据质量管理与控制指标(2016版)的通知［J］.中华人民共和国国家卫生和计划生育委员会公报，2016（5）：28-35.［7］黄锦航.基于DRGs数据的恶性肿瘤病案主要诊断选择分析［J］.中国卫生标准管理，2021，12（12）：40-43.［8］许剑峰，崔丽英，朱焱华，等.基于ICD-10出院诊断问题分析与改进建议［J］.中国卫生质量管理，2017，24（4）：34-36.［9］龙雨曦，袁向东，黎浩.我国医保支付改革下按病种分值付费的探讨与建议［J］.中国卫生质量管理，2022，29（4）：18-20，29.

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更新日期/Last Update: 2024-08-15