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Introducing ICD-0

13/06/2010

Introducing ICD-O-3
The International Classification of Diseases for Oncology,
Third Edition
April Fritz, RHIT, CTR
SEER Program, National Cancer Institute

This presentation covers
• Background for developing ICD-O-3
• What’s new in ICD-O-3
• What’s not new
• Coding guidelines and issues
• Newly reportable hematopoietic diseases

ICD-O-3 Editorial Committee

April Fritz and Constance Percy
National Cancer Institute, USA
Dr Leslie Sobin
Armed Forces Institute of Pathology, USA
Dr K. Shanmugaratnam
National University of Singapore
Dr Andrew Jack
Leeds Teaching Hospitals, UK
Dr Max Parkin and Sharon Whelan
International Agency for Research on Cancer, France

Development of ICD-O-3
• Evolution of cytogenetic and molecular markers
• Identification of morphologic subtypes
• Changes in terminology
• Publication of REAL Classification, 1997
• Publication of WHO/ISUP consensus paper, 1998
• Working party convened, 1998
• Submission of new terms
• Field testing, 1999
• Implementation
CASES DIAGNOSED ON OR AFTER JANUARY 1, 2001

What’s New?
• ~550 new morphology terms and synonyms added 8000-9582
• ~200 new morphology terms added to lymphomas and leukemias

• NO changes to topography

Equivalent Terms
• Mixed/combined small cell ca = large cell-small cell carcinoma
• Sarcomatoid = spindle cell
• Urothelial = transitional cell
• Primary cutaneous neuroendocrine carcinoma = Merkel cell
• Malignant peripheral nerve sheath tumor (MPNST) = neurofibrosarcoma

What’s New?
• Terms from International Histological Typing of Tumours (WHO Blue Books) included
• Major overhaul of lymphomas and leukemias
• Some existing codes moved (combined with other codes)

What’s New?
• More acronyms
» MALT, SALT, BALT mucosa-, skin-, bronchus-associated lymphoid tissue
lymphomas
» PIN, AIN prostatic, anal intraepithelial neoplasia
» DCIS duct carcinoma in situ
» PNET, CPNET, PPNET primitive, central primitive, peripheral primitive
neuroectodermal tumor
» MPNST malignant peripheral nerve sheath tumor

What’s New?
• More specific designation of NOS terms as /0, /1 or /3
• “Crossover” terminology
» Borderline terms that sound malignant
» Malignant terms that don’t sound malignant

Reportable Terms
• Atypical carcinoid
• SETTLE, CASTLE Spindle epithelial tumor showing thymus-like element,
Carcinoma showing thymus-like element
• Rhabdoid tumor, NOS
• Intratubular germ cell neoplasia
• Atypical teratoid/rhabdoid tumor
• Pagetoid reticulosis
• Agnogenic myeloid metaplasia
• Heavy chain disease
• Therapy related myelodysplastic syndrome

What’s New?
• Codes for non-specific diagnoses
» 8046/3 Non-small cell carcinoma
» 8935/3 Stromal sarcoma, NOS
» 9473/3 PNET, NOS
» 9591/3 B-cell lymphoma, NOS
» 9702/3 T-cell lymphoma, NOS
» 9801/3 Stem cell leukemia
» 9860/3 Non-lymphocytic leukemia, NOS

What’s NOT New?
• Matrix principle
• No rule changes
• Older terms retained

Behavior Code Changes
Malignant /3 to Borderline /1
• Borderline tumors of ovary
» 8442/1 serous cystadenoma
» 8451/1 papillary cystadenoma
» 8462/1 serous papillary cystadenoma
» 8472/1 mucinous cystadenoma
» 8473/1 papillary mucinous cystadenoma

Behavior Code Changes
Malignant /3 to Borderline /1
• Pilocytic/juvenile astrocytoma
» Listed as 9421/1 in ICD-O-3
» Will remain reportable as 9421/3
» Sequenced as malignant

Behavior Code Changes
Borderline /1 to Malignant /3
• 8931/3 Endolymphatic stromal myosis (C54.1)
– now a synonym for endometrial stromal sarcoma, low grade

• 9538/3 Papillary meningioma
– malignant version of clear cell/chordoid meningioma

Behavior Code Changes
Borderline /1 to Malignant /3
Myeloproliferative Disorders
• 9950/3 Polycythemia vera
• 9960/3 Chronic myeloproliferative disease
• 9961/3 Myelosclerosis with myeloid metaplasia
• 9962/3 Essential thrombocythemia

Behavior Code Changes
Borderline /1 to Malignant /3
Myelodysplastic Syndromes
• 9980/3 Refractory anemia
• 9982/3 Refractory anemia with sideroblasts
• 9983/3 Refractory anemia with excess blasts
• 9984/3 Refractory anemia with excess blasts in transformation

Additional ICD-9 Casefinding Codes(1)
238 Neoplasm of uncertain behavior of other and unspecified sites and tissues
.4 Polycythemia vera
.5 Histiocytic and mast cells
.6 Plasma cells (plasmacytoma, NOS, solitary myeloma)
.7 Other lymphatic and hematopoietic tissues…

Additional ICD-9 Casefinding Codes(2)
238.7 Other lymphatic and hematopoietic tissues, continued
Chronic lymphoproliferative disease
Chronic myeloproliferative disease
Idiopathic thrombocythemia
Megakaryocytic myelosclerosis
Myelodysplastic syndrome (NOS and therapy related)
Myelosclerosis with myeloid metaplasia
Acute panmyelosis
[Refractory cytopenia with multilineage dysplasia]
[Myelodysplastic syndrome with 5q- syndrome]

Additional ICD-9 Casefinding Codes(3)
273 Disorders of plasma protein metabolism
.2 Franklin’s disease, gamma heavy chain disease
.3 Macroglobulinemia (Waldenstrom’s macroglobulinemia, primary (idiopathic)
macroglobulinemia)
.9 Unspecified disorder of plasma protein metabolism
(screen for potential 273.3 miscodes)

Additional ICD-9 Casefinding Codes(4)
284.9 Aplastic anemia
Aplastic anemia, unspecified
Refractory anemia
Medullary hypoplasia
Aregenerative anemia
Hypoplastic anemia, NOS

285.0 Sideroblastic anemia
Refractory sideroblastic anemia
[Refractory anemia with sideroblasts]
[Refractory anemia with excess blasts]
[Refractory anemia with excess blasts in transformation]

Additional ICD-9 Casefinding Codes(5)
288.3 Eosinophilia
Idiopathic eosinophilia
[Hypereosinophilic syndrome]

289.8 Other specified diseases of blood and blood-forming organs
Hypergammaglobulinemia
Pseudocholinesterase deficiency
Myelofibrosis
Acute myelofibrosis

What’s New?
Genetic Terminology

p short arm
q long arm

– deletion
Chromosome t translocation (swap)
(simplified)
15q AB|CDEF ABKLM
17q GHIJ|KLM GHIJCDEF

Cytogenetic and Molecular Descriptors
9866/3
Acute promyelocytic leukemia t(15;17)(q22;q11-12)
Acute promyelocytic leukemia, PML/RAR-alpha
Acute promyelocytic leukemia, NOS
FAB M3

Cytogenetic and Molecular Descriptors
9875/3
Chronic myelogenous leukemia, BCR/ABL positive
Chronic granulocytic leukemia, t(9;22)(q34;q11)
Chronic granulocytic leukemia, Philadelphia chromosome (Ph1) positive

Leukemia Oncogenes Appearing in ICD-O-3
ABL Abelson murine leukemia oncogene
BCR breakpoint cluster region
CBF core binding factor
ETO eight twenty one (8;21)
MYH11 myosin, heavy polypeptide 11
PML promyelocytic leukemia
RARA retinoic acid receptor, alpha

What’s New?
Cross-referencing
9728/3 Precursor B-cell lymphoblastic lymphoma (see also 9836/3)
9836/3 Precursor B-cell lymphoblastic leukemia (see also 9728/3)

9671/3 Malignant lymphoma, lymphoplasmacytic (see also 9761/3)
9761/3 Waldenstrom macroglobulinemia (C42.0) (see also 9671/3)

“B-cell chronic lymphocytic leukemia/
small lymphocytic lymphoma”
• WHO formal name for disease entity
» had to be split in ICD-10
• 9823/3 cross-referenced to 9670/3
» Malignant lymphoma, small B lymphocytic
• If diagnosed in blood, code 9823/3
• If diagnosed in tissue, code 9670/3

What’s New?
• Instructions rewritten
» More user friendly
» Active verbs
» Simpler statements
» NO change in meaning
» More visual

What’s New?
Table 8. Structure of a Morphology Code

___ ___ ___ ___ / ___ ___
histology behavior differentiation

Example: well-differentiated adenocarcinoma

8 1 4 0 / 3 1

Tumor/cell type Behavior Differentiation
[adeno-] [carcinoma] [well-differentiated]

ICD-O Coding Rules
• Clarified and simplified
• Reorganized
» topography first, then morphology
• Assigned alphabetic labels

RULE A.
Topographic regions and ill-defined sites
If the diagnosis does not specify the tissue of origin, use the appropriate tissues suggested in the alphabetic index for each ill-defined site in preference to the “NOS” category.

RULE B.
Prefixes
If a topographic site is modified by a prefix (such as peri-, para-, or the like) which
is not specifically listed in ICD-O, code to the appropriate ill-defined subcategory C76
(ill-defined site), unless the type of tumor indicates origin from a particular tissue.

RULE C.
Tumors involving more than one topographic category
or subcategory
Use subcategory “.8″ when a tumor overlaps the boundaries of two or more categories
or subcategories and its point of origin cannot be determined.

RULE D.
Topography codes for lymphomas
If multiple lymph node regions are involved by lymphoma, code to C77.8 (lymph nodes of multiple regions).

If no site is indicated for a [nodal] lymphoma, code to C77.9 (lymph node, NOS).

Code extranodal lymphomas to the site of origin, which may not be the site of the biopsy.

If no site is indicated for a lymphoma and it is suspected to be extranodal, code to C80.9 (unknown primary site).

RULE E.
Topography code for leukemias
Code all leukemias except myeloid sarcoma (M-9903/3) to C42.1, bone marrow.

RULE F.
Behavior code in morphology
(The “Matrix Principle”)
Use the appropriate 5th digit behavior code even if the exact term is not listed in ICD-O.

RULE G.
Grading or differentiation code
Assign the highest grade or differentiation code described in the diagnostic statement.

RULE H.
Site-associated morphology terms
Use the topography code provided when a topographic site is not stated in the diagnosis.

This topography code should be disregarded if the tumor is known to arise at another site.

RULE J.
Compound morphology diagnoses
Change the order of word roots in a compound term if the term is not listed in ICD-O-3.

RULE K.
Coding multiple morphology terms
When no single code includes all diagnostic terms, use the numerically higher code number if the diagnosis of a single tumor includes two modifying adjectives with different code numbers.

Other Coding Issues
• Coding of subtypes
» “ductal” (breast)
» “renal cell” (kidney)
» “urothelial” (bladder)
• Definitions of certain terms
• Use of obsolete or archaic terms

Morphology Coding Rules
SEER / NPCR / COC
1. Determine whether single primary or multiple primaries.
» Same first three digits (single)
» Different first three digits (multiple)
° Except lymphatic and hematopoietic diseases

Single Morphology
• If diagnosis is “generic cancer of something type,” code the type.
Example: Duct carcinoma, cribriform type
Code to 8201/3 Cribriform carcinoma

Morphology Coding Rules
SEER / NPCR / COC
2. Coding mixed or multiple morphologies in a single lesion
These rules are in priority order:
a. Use a combination code
b. Code the more specific term
c. Code the majority of the tumor
d. Code the morphology with the highest code

A. Combination Codes
• 8522/_ Ductal and lobular
• 8523/_ Infiltrating duct mixed with other types
• 8524/_ Infiltrating lobular mixed with other types

B. Code the More Specific Morphology
• Non-specific morphologies:
»carcinoma, adenocarcinoma, melanoma, sarcoma
Example: Poorly differentiated carcinoma, probably squamous in origin
Code to 8070/3 Squamous cell carcinoma

C. Majority of Tumor
Majority words
Predominantly
“with features of”

NOT majority words
“with foci of”
“with areas of”
“with elements of”

D. Code the Higher Number
• Used infrequently—rule with lowest priority
Example: Pleural tumor containing malignant mesothelioma and neuroendocrine
carcinoma
Code to 9050/3 Malignant mesothelioma

Format of Index
• NOS term listed first in index
• Most terms indexed under each word
• Lymphomas listed only once
• Leukemias listed only once
• Single instance of a word not bolded
• If 3 or more instances of a word, a bold header is added
• Empty line when list changes from morphology to topography

Structure of ICD-O-3 Index
Melanoma
M-8720/3 NOS
M-8771/3 epithelioid cell
Malignant
M-8745/3 desmoplastic
M-8723/3 regressing

M———- Melanosis, congenital (see SNOMED)

Meninges
C70.9 NOS
C70.0 cerebral
C70.1 spinal

M-8247/3 Merkel cell carcinoma (C44._)
M-8247/3 Merkel cell tumor (C44._)

C49.4 Mesenteric artery

Meaning of NOS
• Not Otherwise Specified
• Not Elsewhere Classified
• Term used in a general sense

Terms Requiring Review
8580/0 Thymoma, NOS (to 8580/1)
8580/3 Thymic carcinoma (to 8586/3)
8930/3 Stromal sarcoma (to 8935/3)
9190/3 Juxtacortical osteosarcoma (to 9192/3)
9190/3 Periosteal osteogenic sarcoma (to 9193/3)
9731/3 Extramedullary plasmacytoma (to 9734/3)
9960/1 Myeloproliferative disease [obs] (to 9975/1)

Ancillary ICD-O-3 Materials Available from SEER
• Conversion tables and programs
» ICD-O-2 to ICD-O-3
» ICD-O-3 to ICD-O-2
» ICD-O-3 to ICD-10
• Hematopoietic primaries table
• Site-type table
• Edits

ICD-O-3 Web Sites
ICD-O-3 Training Web Site

http://www.training.seer.cancer.gov

ICD-O-3 Download Site

http://www.seer.cancer.gov/Admin

NAACCR
Implementation Work Group
• Joint effort of Uniform Data Standards, Information and Technology, Registry Operations and Education committees of NAACCR
• Joint effort of SEER, NPCR, COC, state central registries, vendors
• Guidelines mailed and e-mailed
• Download from http://www.naaccr.org

Ordering Information
Single hardcover copy price: $54.00.
• Quantity discounts available

Order from:
WHO Publications Center USA
49 Sheridan Avenue
Albany, NY 12210
Tel: (518) 436 9686
Fax: (518) 436 74 33
E-mail: QCORP@compuserve.com

Understanding the Newly Reportable
Hematopoietic Diseases

From Stem Cell to Mature Blood Cell

Source: http://www.leukaemia.demon.co.uk/bonecell.jpg

WHO Classification of Hematopoietic and Lymphoid Neoplasms
Lymphoid neoplasms
B-cell, T-cell, NK-cell lymphomas
Hodgkin lymphoma
Lymphocytic leukemias
Other lymphoid malignancies

Myeloid Neoplasms
Myeloproliferative diseases
Myelodysplastic diseases and syndromes
Myeloid leukemias
Acute biphenotypic leukemias

The Lymphomas
• Non-Hodgkin Lymphoma
» WHO Classification–T vs B cell
» De-emphasizing Rappaport, Kiel, Lukes and Collins, Working Formulation

• Hodgkin Lymphoma
» formerly Hodgkin’s Disease
» “classic Hodgkin Lymphoma”– 4 types
» “Hodgkin Lymphoma, nodular lymphocyte predominance”
Equivalent Terms
• Follicular lymphoma = follicle center cell lymphoma
• Mantle cell lymphoma = mantle zone lymphoma
• Anaplastic large B-cell lymphoma = diffuse large cell lymphoma
• Mature T-cell lymphoma, NOS = peripheral T-cell lymphoma

Leukemia Cell Lines

Lymphoid

Myeloid

Leukemia Terminology
-blast early form
-cyte mature form
phenotype cell line

Equivalent Terms
Myeloid Lymphoid
Non-lymphocytic Lymphoblastic
Granulocytic Lymphocytic
Myelogenous Lymphatic
Myelocytic
Monocytic

Other Lymphoid Malignancies
• Solitary plasmacytoma 9731/3
• Multiple myeloma 9732/3
• Plasma cell leukemia 9733/3
• Extramedullary plasmacytoma 9734/3
• Waldenstrom’s macroglobulinemia 9761/3
• Monoclonal gammopathy of
unknown significance 9765/1

Histiocytic and Dendritic Cells
(Accessory Lymphoid Cells)
• Malignant histiocytosis 9750/3
• Langerhans cell histiocytosis, generalized 9752/3
• Histiocytic sarcoma 9755/3
• Langerhans cell sarcoma 9754/3
• Interdigitating dendritic cell sarcoma 9757/3
• Follicular dendritic cell sarcoma 9758/3

Chronic Myeloproliferative Diseases and Disorders
Polycythemia vera 9950/3
Chronic myeloproliferative disease 9960/3
Myelosclerosis with myeloid metaplasia 9961/3
Essential thrombocythemia 9962/3
Chronic neutrophilic leukemia 9963/3
Hypereosinophilic syndrome 9964/3

Myeloproliferative
Definition Overproduction of one or more cell lines developing in bone marrow

Disease Cell Line
Polycythemia vera Erythrocytes
Thrombocythemia Platelets
CMD Multiple cell lines

Polycythemia Vera
Affects Erythrocytes
ICD-9 code 238.4
ICD-O-3 code M-9950/3
Treated by Blood removal, P32 or chemo
Other names Polycythemia rubra vera, p. vera, chronic erythremia (obs),
proliferative polycythemia, primary polycythemia, splenomegalic polycythemia, Vaquez-Osler disease

Essential Thrombocythemia
Affects Platelets/thrombocytes
ICD-9 code 238.7
ICD-O-3 code M-9962/3
Treated by Aspirin, chemo
Other names Idiopathic thrombocythemia, essential hemorrhagic
thrombocythemia, idiopathic hemorrhagic thrombocythemia,
primary thrombocythemia
Chronic Myeloproliferative Disorder
Affects Multiple cell lines
ICD-9 code 238.7
ICD-O-3 code M-9960/3
Treated by Observation; chemo, RT to relieve symptoms
Other names Chronic myeloproliferative disease

Myelosclerosis with Myeloid Metaplasia
Affects Bone marrow stem cells
ICD-9 code 238.7
ICD-O-3 code M-9961/3
Treated by Observation; RT to spleen; transfusions; chemo; splenectomy
Other names Myelofibrosis with myeloid metaplasia, primary myelofibrosis (PMF),
myelofibrosis as a result of myeloproliferative disease,
megakaryocytic myelosclerosis, agnogenic myeloid metaplasia
(AMM)

Myelodysplasia
Definition Defective development of blood cell precursors in the bone marrow
resulting in qualitative and quantitative changes in blood cells.

Other names Pre-leukemia, preleukemic disorders, smoldering leukemia,
oligoblastic leukemia, subacute myeloid leukemia, de novo myelodysplastic syndrome, dysmyelopoietic syndrome, hemopoietic dysplasia

Myelodysplastic Syndromes
Refractory anemia 9980/3
Refractory anemia with sideroblasts 9982/3
Refractory anemia with excess blasts 9983/3
Refractory anemia with excess blasts
in transformation [obs] 9984/3

Refractory Anemia
Affects Reticulocytes
ICD-9 code 284.9
ICD-O-3 code M-9980/3
Treated by Supportive measures
Other names RA, refractory anemia without sideroblasts

Refractory Anemia with Sideroblasts
Affects Reticulocytes
ICD-9 code 285.0
ICD-O-3 code M-9982/3
Treated by Supportive measures
Other names Refractory anemia with ringed sideroblasts, RARS

Refractory Anemia with Excess Blasts
Affects Myeloblasts
ICD-9 code 285.0
ICD-O-3 code M-9983/3
Treated by Transfusions; chemo
Other names RAEB

Refractory Anemia with Excess Blasts in Transformation
Affects Myeloblasts
ICD-9 code 285.0
ICD-O-3 code M-9984/3
Treated by Transfusions; chemo
Other names RAEB-T

New Myelodysplastic Syndromes
Refractory cytopenia with multilineage dysplasia 9985/3
Myelodysplastic syndrome with 5q- (5q deletion) syndrome 9986/3
Therapy related myelodysplastic syndromes 9987/3

Refractory Cytopenia with Multilineage Dysplasia
Affects Multiple cell lines
ICD-9 code 238.7
ICD-O-3 code M-9985/3
Treated by Transfusions

Myelodysplastic Syndrome with 5q- (5q deletion) Syndrome
Affects Myeloid cells
ICD-9 code 238.7
ICD-O-3 code M-9986/3
Treated by Transfusions; chemo

Therapy Related Myelodysplastic Syndrome
Affects Myeloid cells
ICD-9 code 238.7
ICD-O-3 code M-9987/3
Results from treatment with alkylating agents or
epipodophyllotoxins
Other names Secondary myelodysplasia, secondary MDS

Miscellaneous Reportable Terms
Heavy chain disease 9762/3
Immunoproliferative small intestinal disease 9764/3
Myeloid sarcoma 9930/3
Hairy cell leukemia 9940/3
Juvenile myelomonocytic leukemia 9946/3

Record as Treatment
• Chemotherapy
• Radiation therapy
• Surgery
• Immunotherapy
• Bone marrow transplants
• Clinical trials

DO NOT Record as Treatment
• Transfusions
• Phlebotomy/blood removal
• Supportive care
• Aspirin
• Observation

• Do include in remarks field

Registering the Newly Reportable Hematopoietic Diseases (NRHD)
• Accession and abstract only NEW NRHD diagnoses.
• Disregard NRHD cases diagnosed prior to 01/01/01 undergoing active treatment.
• Monitor for transition to another hematopoietic disease.

Abstracting NRHD
Example 1
Refractory anemia with excess blasts diagnosed 6/25/99.
Still receiving transfusions 2/24/01.

Do not abstract.

Abstracting NRHD
Example 2
Refractory anemia with excess blasts diagnosed 6/25/99.
Bone marrow biopsy 3/20/01 shows acute myelogenous leukemia.

Abstract as acute myelogenous leukemia (sequence 00).
Note prior diagnosis in remarks.

Abstracting NRHD
Example 3
Polycythemia vera diagnosed 1/21/01 following 1997 colon cancer.

Abstract polycythemia as a new cancer (sequence 02).

Abstracting NRHD
Example 4
Essential thrombocythemia diagnosed 1/21/01.
Acute myelofibrosis diagnosed 5/19/01.

Abstract essential thrombocythemia as initial cancer. Acute
myelofibrosis is presumably not a second primary according to the
hematopoietic multiple primaries table, but transition should be
noted in remarks.

Hematopoietic Primaries
• New table prepared for ICD-O-3
» Includes myelodysplasias and myeloproliferative disorders
» Based on new medical understanding of cell line diseases
» Not sequence dependent

Table Example
@ one primary only # presumably a second primary

Summary
• Implementation with cases diagnosed on or after 01/01/01
• Contemporary pathologic terminology
• Easier to find diagnoses
• No rules changes

Questions or Comments?
April Fritz, RHIT, CTR
SEER Program, NCI
Room 343J, Executive Plaza North
6130 Executive Blvd Mail Stop 7352
Rockville, MD 20852
e-mail: april.fritz@nih.gov

This presentation has been APPROVED
for 2 continuing education credits by the
National Cancer Registrars Association.

Program Recognition # 2000217

Diproteksi: Contoh Kasus Terminology Medis

13/06/2010

Konten ini diproteksi dengan kata sandi. Untuk melihatnya cukup masukkan kata sandi Anda di bawah ini:

Pengertian ICD

13/06/2010

ICD (International Statistical Clasiffication of Disease and Related Health Problem) atau Klasifikasi Internasional mengenai Penyakit dan masalah yang terkait adalah suatu klasifikasi penyakit, merupakan suatu sistem katagori yang mengelompokkan suatu penyakit menurut kriteria yang telah disepakati.

Volume-1 : Memuat Daftar Tabulasi Lengkap
Volume-2 : Memuat Intruksi Manual / Petunjuk Penggunaan
Volume-3 : Memuat Daftar Indeks Alphabetic
ICD dikelompokkan menjadi ICD 9 CM untuk mengkode tindakan medis, ICD-10 untuk mengkode Diagnosis, ICOPIM untuk mengkode sebab kematian dan ICD-0 untuk menkode Oncology (Kanker)

Baca lebih lanjut

Pengertian Terminology Medis

13/06/2010

Dalam mempelajari Ilmu Penyakit & Laboratorium Kesehatan (IPLK), sebelumnya kita harus mengenal istilah-istilah medis yang sering digunakan dalam dunia kesehatan. Dalam hal ini istilah tersebut sering dikenal dengan nama Terminologi Medis. Terminologi medis merupakan ilmu peristilahan medis.
Beberapa pengertian tentang terminology yaitu:
 The tehnical / special term or expression used in a business, art, science or special subject.
 Nomenclature as a field of study (Webster’s 3rd International Dictionary)
Dalam hubungannya antar profesi kesehatan, dibutuhkan adanya sebuah bahasa komunikasi. Bahasa komunikasi tersebut dikenal dengan istilah medis. Istilah medis merupakan bahasa profesi medis / kesehatan yang merupakan sarana komunikasi antara mereka yang berkecimpung langsung / tidak langsung di bidang asuhan / pelayanan medis / kesehatan. Oleh karena itu, istilah medis ini harus dipahami dan dimengerti oleh setiap profesi kesehatan agar dapat terjalin komunikasi yang baik.

Ilmu terminologi medis ini sangat kompleks dan meliputi:
 Sejarah / riwayat istilah
 Sumber kata
 Manusia yang terlibat (Eponim & Mitologi)
 Anatomi dan Sistem Tubuh
 Penyakit dan Prosedur (tindakan medis)

Pemakai / pengguna terminologi medis yaitu:
 Tenaga Medis
 Tenaga Keperawatan, Bidan
 Tenaga Perekam Medis dan Informasi Kesehatan
 Tenaga Farmasi, Laboratorium, Radiologi, Fisioterapis
 Tenaga Kesehatan lainnya

Konsep Dasar Struktur Istilah Medis
Sebagian besar istilah berasal dari bahasa Yunani Kuno (G) dan Latin (L). Untuk istilah organ tubuh, bahasa yang digunakan berasal dari bahasa Latin. Sedangkan untuk istilah penyakit, menggunakan bahasa dari Yunani.
Contoh:
1. Marrow [L] ini sistilah anatomi untuk sumsum tulang
Myelitis [G] ini istilah penyakit untuk radang sumsum tulang
2. Pulmo [L] ini istilah untuk organ tubuh paru
Pneumonia [G] ini istilah penyakit untuk radang paru

Contoh Istilah Asal Zaman Hippocratus (460 – 370 SM)
Lafal Istilah Arti Istilah
1. Ureter [G, oureter] = pipa sempiat saluran urine ke luar dari ren (ginjal) kanan/kiri menuju ke vesica urinaria (kantung kemih)
2. Peritoneum [G, peritonaien] = membrane serosa yang melapisi bagian dalam cavum abdominalis dan viscera yang ada di dalamnya
3. Meninges = membrane otak [G, meninx, spinal cord] terdiri dari 3 lapis:
a. Dura-mater
b. Pia-mater
c. Arachnoidea
4. Bronch’chus (s) [G, brogchos] = cabang primer bronchi (pl)
Pipa trachea (di bagian dalam paru) dan terdiri dari tulang rawan, otot
5. Thorax (s) = dada = rongga tubuh di atas sekat perut (diaphragma) di bawah leher, berdinding:
 Depan : tulang dada = sternum
 Samping ka/ki : iga = costa (s) costae (pl)
 Belakang : tl. Punggung = vertebrae (pl)
Isi rongga thorax:
• Cor (jantung) yang terbungkus pericardium
• Pulmo (paru) ka/ki yang terbungkus pleura
• Mediastinum structure (structure bagian tengah)

Contoh Istilah Asal Zaman Aristotles (385 – 322 SM)
Lafal Istilah Arti Istilah
1. Alopecia = botak
[G, alopekia Alopex = fox] (sebutan sejenis penyakit srigala akibat infeksi kulit kepala -> luka -> koreng -> rambut rontok -> botak)
2. Glaucoma [G, glaukoma] = penyakit mata yang ditandai dengan naiknya tekanan intra-ocular
Jenis glaucoma, diantaranya:
 Acute glaucoma
 Congenital glaucoma
 Hemorrhage glaucoma
 Malignant glaucoma
 Secondary glaucoma
 Simple glaucoma (chronic)

Contoh Istilah Asal dari Nama Hewan
Istilah/Asal Arti Istilah
1. Karcinos [G] = crab (kepiting)
Carcinoma = cancer (kanker)
2. Lupus [L] = wolf (srigala)
Lupus (vulgaris) = UKK TB kronik & TB pada selaput lendir
3. Cauda [L] = tail (ekor) = yang berkaitan dengan bagian ekor, bagian buntut
Caudad = ke arah menuju ekor
[L + ad L]

4. Cochlea [L] = snail (siput)
Kochlos [G] = shellfish (keong)
Sebutan untuk rongga telinga internal
5. Musculus [L] = tikus kecil  muscle (otot)
6. Vermis [L] = worm (cacing) = Lobus medialis cerebellum di antara hemisphere atau lobus lateralis

Contoh Istilah Terpengaruh Kebudayaan Zamannya
 Zaman Helenistis (jaman banyak peperangan)
o Xiphoid [G, xiphoedes] = sword shaped = anggar
o Thyroid [G, thyreoides] = shield shaped = perisai, tameng
o Thorax = breast plate = baju plate besi rompi pelindung dada waktu perang
o Staoes [L] = strirrup = tempat pijakan kaki penunggang kuda
o Sella [L, seat] = saddle = pelana kuda
o Ossicle [L, ossiculum] = malleus = hammer = palu
o Incus [L, avil] = landasan alat pandai besi
 Nama Alat Musik
o Salpinx [G, salpigx] = trompet
o Tympanum [G] = drum (tambur)

ISTILAH KEDOKTERAN
Istilah medis terbentuk dari bagian-bagian komponen / unsur kata yang disebut:
A. Prefix (awalan)
- Unsur kata yang terletak di bagian terdepan dari istilah medis (mendahului root)
- Fungsinya sebagai awalan
B. Root (akar kata)
- Pada umumnya terletak di tengah (diantara prefix dan suffix)
- Setiap istilah medis mempunyai root
- Fungsinya sebagai dasar/inti dari istilah medis yang terkait
C. Suffix (akhiran)
- Unsur kata yang terletak di bagian paling belakang dari istilah medis yang terkait (selalu mengikuti root atau pseudoroot)
- Fungsinya sebagai kata akhiran

Catatan:
Tidak semua istilah medis mengandung unsur kata prefix atau root atau suffix secara lengkap

Contoh :
A. 1. ISTILAH MEDIS YANG MENGANDUNG 3 UNSUR KATA
a. PREFIX ROOT SUFFIX
Meta morph osis
Peri cardi ectomy
Epi gastr algia

b. PREFIX ROOT PSEUDOSUFFIX
Trans urethr al
Hyper therm ia
Anta gen ist

c. ROOT ROOT PSEUDOSUFFIX
Sterno clavicul ar
Gastro intestin al
Psych somat ic

d. ROOT PSEUDOROOT SUFFIX
Rhino pharing it is
Gastro duodeno stomy
Electro enchepalo graphy
Electro cardio graphy

A. 2. ISTILAH MEDIS YANG MENGANDUNG 2 JENIS UNSUR KATA
a. PREFIX PSEUDOROOT tanpa SUFFIX
Ante natal -
Peri anal -
Hyper tensia -

b. ROOT PSEUDOSUFFIX tanpa PREFIX
Neur al -
Odont ic -
Pulmonar y -

c. ROOT SUFFIX tanpa PREFIX
Odont algia -
Broncho phaty -
Tox oid -

d. ROOT PSEUDOROOT tanpa PREFIX /SUFFIX
Thermo meter -
Entero cyst -
Nephro lith -

A. 3. ISTILAH MEDIS YANG MENGANDUNG LEBIH DARI 3 KATA
PREFIX ROOT ROOT SUFFIX
Pan colpo hyster ectomy
Uretro pyelo nephro stomy
Peri encephalo mening it is

A. 4. BENTUK SUSUNAN ISTILAH MEDIS YANG TERJADI DARI GABUNGAN DUA ISTILAH MEDIS
1. Osteo…..chondro…..dys…..trophia
2. Osteo…..chondro….dys…..plasia
3. Osteo……fibro…..condr…..oma

STRUKTUR DASAR ISTILAH
1. Unsur kata ROOT adalah dasar dari suatu istilah gastric, dari root gaster
2. Unsur kata SUFFIX adalah kata akhiran pada istilah gastritis, yang terdiri dari root gast- dan suffix -itis yang mempunyai arti radang
gastritis = radang lambung
3. Unsur kata PREFIX adalah kata depan pada istilah epigastritis, terdiri dari prefix epi-, root -gastr- dan suffix -itis.
Epigastritis = radang pada lambung bagian atas
Contoh lain = epigastralgia, epigastric
4. Huruf hidup penggabung (sisipan) adalah huruf yang digunakan untuk merangkai unsur kata Root ke Suffix atau Root ke Root lain.

Contoh : cardio-o-gram
detr-o-cardia
ventr-o-lateral
electr-o-cardi-o-gram
trache-o-bronch-o-scopy
5. Bentuk penggabung (combining form).
Bentuk penggabung adalah bagian istilah yang terdiri dari Root dan huruf hidup penggabungnya.
Contoh : aden-o-
encephal-o-
meningi-o-
hem-o-
hepat-o-
oste-o-
thromb-o-

UNSUR KATA PEMBENTUK ISTILAH
Ada 3 jenis unsur kata utama:
A. Suffixes
B. Prefixes
C. Roots

Contoh:
1. GASTROENTEROLOGY  GAST-O-ENTER-O-LOGY
root root suffix
Huruf “o” bertugas sebagai huruf penggabung.
gastr- dari gaster = lambung
enter- dari enteron = usus
-logy = proses studi

2. ELECTROCARDIOGRAM  ELECTR-O-CARDI-O-GRAM
root root suffix
electr- dari Electron = listrik
cardi- dari cardium = jantung
gram = record

3. ONCOGENIC  ONC/ O /GEN/ IC
Di sini karena suffix –ic dimulai dengan huruf hidup maka tidak disisipi huruf “o”

4. GASTROENTERIC tidak dieja dengan GASTR ENTERIC
Apabila dua roots harus digabung maka walau root kedua dimulai dengan huruf hidup tetap diperlukan sisipan huruf “o” di antara kedua root terikat, untuk memperindah lafal.

ROOTS SESUAI SISTEM ORGAN TUBUH

A. Root / Combining Form Integumentum System
Contoh :
Root Arti
Bucco- pipi
Cheilo- bibir
Derm-, Dermat-(o) kulit
Fibro- serat fiber
Hist- jaringan
Kerato- jaringan tanduk
Labi- bibir
Masto-, Mammo- payudara
Onych- kuku
Pilo- rambut
Sarc- daging
Somatic tubuh
B. Root / Combining Form Musculoskeletal System
Root Arti
Arthro- sendi
Chondro- tulang rawan
Cleido- clavicula
Costo- iga
Gnatho- dagu
Ili- usus ilium
My- otot
Osteo- tulang
Phren- diaphragma
Sacro- sakrum
Spondylo- vertebra
Ten-, Teno-, Tendo-, tendon (urat)
Tenonto-
C. Root / Combining Form respiratory & Circulatory System
Root Arti
Broncho- bronkus
Laryngo- laring
Pleur- pleura
Pneum-, Pulmo-, Pneumato- udara, gas, paru
Rhini-, Naso- hidung
Trache- trakea
Angio- pembuluh darah
Arterio- arteri
Cardi-, Cardio- jantung
Phleb, Ven vena
Pylo- pilorus
Thrombo-, Thrombus trombus
Vas pembuluh, saluran
D. Root / Combining Form Hemic, Lymphatic, Endocrine & Nervous System
Root Arti
Aden- kelenjar
Hem-, Hema-, Hemat-a (o), darah
Hemo-
Lien-, Splen- limpa
Lymph- lemfe
Plasm- plasma
Adreno- kelenjar adrenal
Thyro- kelenjar gondok
Enchepalo- otak
Mening- otak dan spinal cord
Myel- sumsum tulang
Neur- nerves, saraf
E. Root / Combining Form Digestive System
Root Arti
Dent-, Debta-, Denti-, Dento- gigi
Odont-, Odonto
Enter- usus
Gastro- lambung
Gingiv- gusi
Hepat- hati
Ile- ileum
Linguo-, Gloss- lidah
Or-, Os-, Stoma mulut
Pharyng- faring
Proct- rectum
Pyloro- pilorus
Sial- ludah
F. Root / Combining Form Urogenital System
Root Arti
Balano- glans penis
Colpo- vagina
Cyst-, Cyati-, Cysto- kandung kemih
Episio- vulva
Hystero-, Metro- uterus
Nephro-, Ren ginjal
Oophor- ovary
Orchi-, Orchido- testis
Pyel- pelvis ginjal
Ur- urine, saluran urine
Ureter- saluran ureter
Urethro uretra

G. Root / Combining Form Eye & Ear (mata dan telinga)
Root Arti
Blepharo- kelopak mata
Core- pupil mata
Irid- iris mata
Kerato- kornea mata
Oculo- mata
Ophthalm- mata
Ot- telinga
Phaco- lensa mata

Pengertian dari Rekam Medis

29/05/2010

Rekam medis adalah keterangan baik yang tertulis maupun terekam tentang identitas ,
anamnesa,penentuan fisik , laboratorium, diagnosa segala pelayanan dan tindakan medik
yang diberikan kepada pasien dan pengobatan baik yang dirawat inap , rawat jalan maupun
yang mendapatkan pelayanan gawat darurat .
Rekam medis mempunyai pengertian yang sangat luas , tidak hanya sekedar kegiatan
pencatatan, akan tetapi mempunyai pengertian sebagai suatu sistem penyelenggaraan rekam
medis yaitu mulai pencatatan selama pasien mendapatkan pelayanan medik , dilanjutkan
dengan penanganan berkas rekam medis yang meliputi penyelenggaraan penyimpanan serta
pengeluaran berkas dari tempat penyimpanan untuk melayani permintaan/peminjaman
apabila dari pasien atau untuk keperluan lainnya
Rekam medis mempunyai 2 bagian yang perlu diperhatikan yaitu bagian pertama
adalah tentang INDIVIDU : suatu informasi tentang kondisi kesehatan dan penyakit pasien
yang bersangkutan dan sering disebut PATIENT RECORD, bagian kedua adalah tentang
MANAJEMEN: suatu informasi tentang pertanggungjawaban apakah dari segi manajemen
maupun keuangan dari kondisi kesehatan dan penyakit pasien yang bersangkutan
Rekam medis juga merupakan kompilasi fakta tentang kondisi kesehatan dan penyakit
seorang pasien yang meliputi 2:
- data terdokumentasi tentang keadaan sakit sekarang dan waktu lampau
- pengobatan yang telah dan akan dilakukan oleh tenaga kesehatan profesional secara
tertulis.
Secara umum, informasi yang tercantum dalam rekam medis seorang pasien harus
meliputi 2:
- Siapa (Who) pasien tersebut dan Siapa (Who) yang memberikan pelayanan
kesehatan/medis

- Apa (What), Kapan (When) , Kenapa (Why) dan Bagaimana (How) pelayanan
kesehatan/medis diberikan
- Hasil akhir atau dampak (Outcome) dari pelayanan kesehatan dan pengobatan

Ikuti

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