摘要
出血性脑血管病包括蛛网膜下腔出血、脑出血和其他颅内出血,基于CN-DRG(2020版)分析出血性脑血管病疾病手术编码及DRG入组情况。蛛网膜下腔出血常用手术操作为开颅夹闭治疗和血管介入栓塞治疗,脑出血、硬膜下和硬膜外出血常用手术操作为血肿清除术、血肿穿刺引流和去骨瓣减压。非创伤性颅内出血,内科组无论部位均入组BR1,手术组行开颅血肿清除术时入组BB1;蛛网膜下腔出血行开颅动脉瘤夹闭、包裹术入组BC1,行栓塞介入治疗入组BE1。创伤性颅内出血,内科组的多系统损伤入组ZR1或ZR2,单纯颅内出血入组BY1或BY2;手术组行开颅血肿清除术入组ZB1或ZB1。两类出血性脑血管病行颅脑血肿穿刺引流时均入组BJ1。医疗机构应提升编码员的自身能力,完善构建“临床-编码-分组”的知识体系,将临床-编码-DRG这3个环节紧紧结合、从DRG中去印证临床,从编码中去支撑分组,才能更有效的提升住院病案首页数据质量,服务临床、支撑管理与评价。
Hemorrhagic cerebrovascular diseases include subarachnoid hemorrhage,cerebral hemorrhage,and other intracranial hemorrhages.Based on CN-DRG(2020 edition),this study analyzes the surgical coding and DRG grouping of hemorrhagic cerebrovascular diseases.Common surgical procedures for subarachnoid hemorrhage include craniotomy with aneurysm clipping and endovascular embolization.For cerebral hemorrhage,subdural hemorrhage,and epidural hemorrhage,commonly used procedures include hematoma evacuation,hematoma puncture and drainage,and decompressive craniectomy.Non-traumatic intracranial hemorrhage with conservative treatment,regardless of location,was included in group BR1.Non-traumatic intracranial hemorrhage with craniotomy hematoma clearance surgery was included in group BB1.Subarachnoid hemorrhage(I60)with craniotomy aneurysm clipping and wrapping surgery was included in group BC1 while with Interventional treatment such as aneurysm embolization regardless of the type of embolization material used(excluding 39.7203)group was included in group BE1.Traumatic intracranial hemorrhage with multiple system injuries in the internal medicine group were included in ZR1 or ZR2,while simple intracranial hemorrhage was included in BY1 or BY2.Traumatic intracranial hemorrhage with craniotomy hematoma clearance surgery was included in ZB1 or BB1.Both types of hemorrhagic cerebrovascular disease were included in group BJ1 when undergoing cerebral hematoma puncture drainage.Medical institutions should enhance the capabilities of coders and improve the construction of an integrated knowledge system linking"clinical practice,coding,and grouping."By closely connecting the three components—clinical practice,coding,and DRG—and using DRG to validate clinical data and coding to support grouping,institutions can more effectively improve the quality of front-page medical record data,thereby supporting clinical work,management,and evaluation.
作者
熊莺
罗文慧
林卓琛
Xiong Ying;Luo Wenhui;Lin Zhuochen(Department of Quality Control and Evaluation,First Affiliated Hospital of Sun Yat-sen University,Guangzhou 510080,Guangdong Province,China;不详)
出处
《中国病案》
2025年第7期37-40,共4页
Chinese Medical Record
关键词
出血性脑血管病
ICD
DRG
Hemorrhagic cerebrovascular disease
International classification of diseases
Diagnosis-related groups
