2016-01-30-世界卫生组织-International_statistical_classification_of_diseases_and_related_health_problems,_ICD-10_Volume_2_252页_1mb

ICD-10 Instruction Manual Summary

Core Content

The International Statistical Classification of Diseases and Related Health Problems (ICD-10) is the 10th revision of the WHO classification system, designed for the systematic recording, analysis, interpretation, and comparison of mortality and morbidity data globally. This document serves as the Instruction Manual for ICD-10, providing detailed guidelines for its application, along with an overview of its structure, purpose, and related classifications.

Main Purpose and Applicability

• Purpose: The ICD-10 is intended to provide a standardized system for classifying diseases and health problems, enabling international comparisons and supporting health statistics.
• Applicability: It is used for recording and coding diagnoses on health and vital records, and is suitable for epidemiological, health management, and research purposes.
• Limitations: It is not designed for indexing distinct clinical entities or for financial aspects like billing and resource allocation.

Structure of ICD-10

• The ICD-10 is divided into three volumes:

  • Volume 1: Tabular list
  • Volume 2: Instruction manual (this document)
  • Volume 3: Alphabetical index

• Classification Components:

  • Chapters: 21 chapters, each covering a specific category of diseases.
  • Blocks of categories: Grouping of related diseases.
  • Three-character categories: Broad classification of diseases.
  • Four-character subcategories: More specific classifications.
  • Supplementary subdivisions: Additional detail at the fifth or subsequent character level.
  • Chapter XXII (U codes): Used for factors influencing health status and contact with health services.

Guidelines for Use

• Volume 1: Contains the tabular list of categories and subcategories. It includes:

  • Introduction
  • Use of the Tabular list and four-character subcategories
  • Instructions for two codes for certain conditions
  • Conventions used in the Tabular list
  • Categories with common characteristics

• Volume 3: Contains the Alphabetical index, with:

  • Arrangement and structure
  • Code numbers
  • Conventions
  • Detailed instructions on how to use the index

• Basic coding guidelines:

  • Accurate and consistent coding is essential for data interpretation and comparison.
  • Coders must use the appropriate code based on the clinical documentation.
  • Special attention is required for certain conditions, such as malignant neoplasms, sequelae, and multiple causes of death.

Mortality and Morbidity Coding Rules

• Mortality coding:

  • Focuses on identifying the underlying cause of death.
  • Includes special instructions for:
    • Finding the starting point (Steps SP1 to SP8)
    • Modifying the starting point (Steps M1 to M4)
    • Accepted and rejected sequences
    • Obvious cause of death
    • Linkages and other provisions
    • Main injury in external causes
    • Poisoning by drugs and biological substances
    • Maternal mortality
    • Surgery and medical procedures

• Multiple causes of death:

  • Guidelines for selecting and coding multiple causes.
  • Includes rules for:
    • Uncertain diagnosis
    • Either...or conditions
    • Effect of connecting terms
    • Malignant neoplasms
    • Sequelae
    • Other ICD categories
    • Consistency between sex and diagnosis

• Perinatal mortality:

  • Guidelines for certification and coding of perinatal deaths.
  • Includes:
    • Certification of perinatal deaths
    • Statement of causes of death
    • Tabulation of perinatal mortality by cause
    • Coding rules for perinatal causes

• Morbidity coding:

  • Guidelines for recording and coding single-condition and multiple-condition data.
  • Includes:
    • Recording diagnostic information
    • Coding 'main condition' and 'other conditions'
    • Rules for reselection if the main condition is incorrectly recorded
    • Chapter-specific notes

Special Tabulation Lists

• The ICD-10 includes special tabulation lists for data presentation and analysis:
  • Five special tabulation lists for mortality and one for morbidity.
  • These lists are designed to facilitate international comparisons and publications.

WHO Family of International Classifications (WHO-FIC)

• The ICD-10 is part of the WHO-FIC, which includes:
  • Reference classifications: ICD-10 (mortality and morbidity), ICF (functioning, disability, and health).
  • Derived classifications: Specialty-based adaptations like ICD-O-3 (oncology), ICD-DA (dentistry), ICD-10-NA (neurology), ICD-R&O (rheumatology and orthopaedics), and ICD-10 for paediatrics and mental disorders.
  • Related classifications: ICPM (procedures in medicine), ICPC-2 (primary care), ICECI (external causes of injury), ISO 9999 (technical aids for disabilities), and ATC/DDD (anatomical therapeutic chemical classification with defined daily doses).

Key Information

• The ICD-10 is a standardized classification system used globally.
• The ICF introduces a new framework for classifying health and disability, focusing on functioning, environmental factors, and contextual influences.
• The WHO-FIC is a family of classifications that supports comprehensive health data collection and analysis.
• The special tabulation lists are essential for statistical reporting and international comparison.
• The ICD-10 Instruction Manual is not a training manual but a guide for proper application and interpretation of the classification system.

Conclusion

This document outlines the practical use and interpretation of ICD-10, emphasizing its role in mortality and morbidity statistics, international comparability, and integration with other WHO classifications. It also highlights the importance of specialty adaptations and related classifications in providing a comprehensive view of health and healthcare.