Terms in oncology. Cancer disease

Each patient wants to know what happened to him, and therefore, first of all, he wants to hear from the doctor the name of his disease, the diagnosis. However, it can be difficult to understand tricky medical terms. In this case, certain information about what a particular disease is can be obtained directly from its name.

SO, there are many diseases whose names are formed from some anatomical term, usually of Latin or Greek origin, and a word-formation element that indicates a particular violation of the function of an organ or system. For example, the presence in the name of the Greek prefix "a" (before vowels - "an") means negation, the absence of any quality. These are diseases such as anemia("gema" - blood) - in literal translation means "bloodlessness" (practically - "anemia"); asthenia("stenos" - strength) - literally "impotence", "general weakness"; atrophy("trophy" - nutrition) - lack of nutrition; arrhythmia- literally "no rhythm", that is, any violation of the heart rhythm; anuria("urine" - urine) - "no urine", cessation of urination, etc.

If the Greek prefix "dis" is present in the name of the disease, it means a disorder, a difficulty in the function of one or another organ. According to this principle, the names of diseases such as dystrophy- malnutrition; dyskinesia("kinesis" - movement) - a violation of the contractile function of the digestive organs; dystonia("tonos" - tension) - a violation of the nervous regulation of vascular tone; dysbacteriosis("bacterion" - stick) - a violation of the biological balance between pathogenic and beneficial bacteria in the intestine; dysentery("enteron" - gut) - literally means "intestinal disorder", etc.

When the name ends in "-itis", the disease usually has an inflammatory character. For example, arthritis("artron" - joint) - inflammatory disease of the joint; gastritis("gaster" - stomach) - an inflammatory disease of the gastric mucosa; dermatitis("derma" - skin) - inflammation of the skin; mastitis("mastos" - chest) - inflammation of the mammary gland; nephritis("nephros" - kidney) - an inflammatory disease of the kidneys; phlebitis("phlebos" - vein) - inflammation of the veins, etc.

Many oncological diseases can be identified by the presence in the name of the derivational element "-oma", meaning "tumor". For example, angioma("angion" - vessel) - vascular tumor; myoma("mios" - muscle) - a tumor of muscle tissue; nephroma- malignant tumor of the kidney, etc.

The ending "-pathia" ("pathos" - disease, suffering) means the general name of the diseases of any organ or system. For example, arthropathy- common name for diseases of the joints; nephropathy- kidney disease; psychopathy("psyche" - soul, consciousness) - character pathologies; cardiopathy("cardia" - heart) - heart disease, etc.

Often the name of the disease indicates its main clinical symptom. For example, the presence of the word-building element "-alg-" ("algos" - pain): neuralgia("neoron" - nerve) - pain along the nerve; gastralgia- stomach ache; myalgia- muscle pain, etc. The names of diseases such as hemophilia("gema" - blood and "filia" - a tendency) - a predisposition to bleeding; schizophrenia("schizo" - split, split and "fren" - soul, mind, mind) - a split personality; haemorrhoids("gema" - blood and "roa" - expiration) - bleeding, bleeding; hypertension("hyper" - above, above and "tonos" - tension) - increased tension of blood vessels; angina("ango" - soul) - suffocation; scarlet fever("scarlatum" - bright red tissue) - redness of the mucous membrane of the oropharynx; stroke("stroke" - stroke) - characterizes the sudden onset of the disease, etc.

The name of the disease may indicate the underlying pathological process. For example, atherosclerosis("atere" - slurry and "scleros" - dense, hard) - a combination of thickening (sclerosis) of the inner lining of the artery and the accumulation of fatty substances in it, which eventually acquire the appearance of slurry. Cardiac ischemia("ischemia" - to delay, stop the blood) - damage to the heart muscle caused by a disorder of the coronary circulation; caries("rotting") - the destruction of tooth tissues.

From some names, you can also find out the direct cause of the disease. For example, title "hay fever"("pollen" - pollen) indicates the relationship of this disease with plant pollen; brucellosis- a disease caused by various types of Brucella; leptospirosis- a disease caused by leptospira, etc.

There are also more complex names. For example, myocardial dystrophy("mios" - muscle, "cardia" - heart, "dystrophy" - malnutrition) - non-inflammatory damage to the heart muscle in the form of a violation of its nutrition. In the name of the disease "tick-borne Lyme borreliosis" the vector (tick), pathogen (borrelia) and the place where this disease was first described (Lyme in the USA) are indicated. And from the title "tick-borne encephalitis" you can find out that the main pathological process of this disease is inflammation of the brain ("encephalon" - the brain, and the ending "-it" means inflammation) and that the causative agent of the disease is carried by ticks.

However, there are a number of diseases whose names do not reflect their true nature. The fact is that these names appeared at a time when the true causes of many diseases were not yet known. But, despite this, some of these names are still used to refer to a number of diseases. For example, glaucoma("glaukos" - bluish) literally means "bluish clouding of the lens", although, as you know, the basis of this disease is an increase in intraocular pressure.

The name of such a disease has survived to this day, as "gonorrhea", a characteristic symptom of which are purulent discharge. But when the Roman physician Galen in the II century AD. e. proposed this name, it was believed that the essence of the disease lies in the flow of seminal fluid: in Greek, "gonorrhea" means "semen flow" ("gonos" - seed and "roe" - flow). And although it was later found that pus is released, the original name remains.

The occurrence of a disease such as "hysteria", ancient Greek doctors associated with disorders of the uterus. Hence the name "hysteria", derived from the Greek. "hyster" - uterus. But even after it has been shown that the symptoms characteristic of this disease depend on the disorder of the nervous system, the term "hysteria" continues to be used to designate a neuropsychiatric disease related to neuroses.

For more than two millennia, it was believed that prolonged inhalation of heavy swamp fumes causes a disease, which in connection with this received the name "malaria"(from the Italian "mala aria" - bad air). And although the true reason for its occurrence was later revealed, the old name has survived to this day.

What does sick leave mean? With the help of a sick leave, an illness, injury or other physiological problems of an employee are registered. The form is sometimes called differently - a sheet of temporary disability. It is allowed to be prescribed only to doctors who have passed a special check by the FSS. An employee can count on payments if the form was correctly filled out and submitted to the administration of the enterprise on time.

For a long time, a single standardized form has been used to fill out sick leave. In 2011, a reform was made in this area, the forms began to look a little different, and new rules for filling out were introduced. Disease codes have become strictly mandatory.

Is the diagnosis written on the sick leave? The diagnosis and cause of disability are now indicated using two special digital designations. The first is the national designation of the cause (01,02,03), the second is the international form of recording the disease according to the ICD-10 system.

First of all, the reform was carried out to avoid cases of fraud related to sick pay. That is why in all honey. Institutions forms come directly through the offices of the FSS. Serial numbers are put down on the sheets, so it becomes much easier to track illegal fraud. In addition, new sheets are protected with watermarks, micro-text and some other methods.

It is best to fill out the sheet using printed media, as well as with a black pen. Entries must be placed exactly within the boundaries of cells and frames. Such accuracy is necessary so that the form can be processed by a computer - electronic reading is quite sensitive and demanding. The physician must not cross out, sign, or otherwise alter the completed form.

A sample of a completed sick leave:

If you need to change the information, then you should take a new sheet. The employer has the right to make mistakes and make corrections to the records, but this is highly undesirable. Corrections are written on the back of the sheet, incorrect data are crossed out.

Then you should sign and date, fix the fact of corrections. Also, we advise you to read the article, from which you will learn about inaccuracies that FSS employees will not pay attention to.

The form is filled out by two - a doctor and an employer. The doctor is responsible for completing the 1st and 3rd sections. The employer, in turn, is for the second. It should be borne in mind that the FSS performs quality control and random checks. In the future, the Fund plans to switch completely to the electronic sick leave system, which will further simplify the task of monitoring.

When applying for / using sick leave, you should rely on the Tax, Labor and Administrative Code. In addition, important documents are Federal Laws N212, N125, N255. In any unclear cases, you should contact the FSS department for advice.

On the back of the sheet you can always find instructions for filling out, as well as decoding all the codes.

Registration procedure

Three people are involved in the registration - a doctor, an employer and an employee. An employee who falls ill is sent to a medical facility. The doctor must diagnose the disease and the patient's state of health. On its basis, the physician determines the period of sick leave and enters it into the form. To do this, use the appropriate unified codes (detailed explanation below). Then he specifies the following information about the patient:

Date of Birth;
The name of the enterprise - according to the patient, no special documents are required. If the employer is an individual entrepreneur, then enter the full name of the individual. employer person.

The physician must also provide the name, address, and registration number of their medical facility. After that, the sheet should be signed and stamped. If the attending physician is engaged in private practice, then he similarly indicates his full name and register. number.

The employee takes the form filled out by the doctor to the administration at the place of work. The employer fills in information regarding the calculation of payments and information about his company:

Name of the organization - 29 cells are allocated, one empty cell must be left between the words;
Type of work (main or part-time);
Registration number in the FSS (enterprise);
Subordination code;
Employee number (identification);
Fear. number;
Payment terms;
Fear. employee's length of service;
Avg. earnings;
Name of heads. accountant and head of the enterprise;
Amount of payments - indicate three amounts: from the employer, from the Fund and the total amount (due to the employee).

In addition, the data necessary for the tax is recorded. Every year, all employees must file tax reports (2-NDFL). On sick leave, the tax code is always the number 2300. The benefit is not taxed, although it is formally classified as income. A 2-NDFL certificate is sometimes required for an employee to get a loan; it may be necessary at a new workplace. The employee always has the opportunity to check the correctness of payments.

Deciphering the fields in the sick leave:

The employee is also a participant in the registration process, but he fills in almost nothing. He is only required to consult a doctor in a timely manner, to receive a certificate of incapacity for work. Then it is necessary (in compliance with the deadlines) to provide the completed form at the place of work.

Codes

Special digital codes are used to record information describing the nature (diagnosis, disease, cause) and duration of disability. Codes are two-digit and three-digit (start from zero). With this flexible system, all causes of disability/sick leave are coded. There are 15 main causes of disability(diseases), let's look at what the codes on the sick leave mean, what disease and diagnosis is hidden behind it, and let's decipher them:

"01" - disease, the most common case, especially during influenza epidemics;
"02" - domestic injury, that is, damage to the body received not at work / workplace;
"03" - quarantine, indicates the need for quarantine, typical for infectious diseases, such as tuberculosis;
"04" - industrial injury, but the correct name would be "accident at work";
"05" - the onset of disability due to BiR (pregnancy and childbirth);
"06" - prosthetics, which (for medical reasons) can only be done in a hospital;
"07" - prof. disease, as well as exacerbation of prof. diseases, especially typical for industries with harmful conditions;
"08" - medical procedures in hospitals and sanatoriums;
"09" - disability due to the need to care for a sick family member (for example, a disabled person);
"10" - poisoning, as well as other conditions;
"11" - a disease from the list of social. significant diseases, the list is approved by Government Decree N715. These include, in particular, tuberculosis, hepatitis, HIV, diabetes, oncology;
"12" - the cause is the illness of a child under 7 years old, the need for additional care for him;
"13" - care for a disabled child;
"14" - an oncological disease in a child or a post-vaccination complication;
"15" - HIV infection in a child.

Items "14" and "15" are noted in the form only with the consent of the insured person (employee).

After the code "15", three-digit designations begin (the first is "017"), they are indicated next to the above two-digit ones. At their core, they are incremental, give more detail if necessary, and they start with the number "0". In total, there are five such designations:

"017" - indicate if the treatment took place in a special. sanatoriums;
"018" - undergoing sanatorium treatment due to an industrial injury;
"019" - treatment at the clinic at the university / institute;
"020" - add. vacation in BiR;
"021" - note if the disease / injury was obtained as a result of the use of alcohol and drugs.

Thus, correlating the cause with the established list, the doctor enters the cause in the form. For example, if a woman is on sick leave in BiR and received additional leave for this reason, the codes “05” and “017” will be indicated on the form.

Then, in the lines "Other" and , the code again becomes two-digit. Let's see what some of the codes in the "Other" section mean:

"31" - note if the employee continues to be sick;
"32" - the employee was assigned a disability;
"34" - death (in this case: the reason for the end of the sick leave);
"36" - the patient appeared (at the appointment) healthy and able-bodied.

In addition to codes for the causes of disability, there are so-called ICD codes (International Classification of Diseases). The latest version is ICD-10 - the tenth edition of this classification. The doctor in the hospital also notes the disease according to the ICD system. In total, 22 classes of diseases are distinguished. They are assigned a designation from "A00" to "Z100". The ICD is already fully medical information.

If the doctor made a mistake when filling out the codes, then he must take a new, clean form. He is not allowed to cross out, sign and make changes.

Conclusion

A sick leave certificate is required when registering a temporary disability of an employee. In 2011, in order to optimize the workflow and reduce the costs of the FSS, a reform was carried out. Causes and diseases are recorded using digital symbols called codes.

Information is indicated using two designations - the first is the national designation of the cause of disability (for example, injury, disease), the second is the international designation of the disease according to the ICD-10 system, it provides more detailed medical information.

The alphanumeric combination that the doctor put in his medical instead of an understandable, detailed diagnosis? And it's not just curiosity - it's just that many people are used to controlling the situation, and the unknown contributes little to this.

International Classification of Diseases and Related Health Problems 10th Revision (ICD10)

The current one was adopted by the 43rd World Health Assembly in 1989. The principle is simple - all diseases and health problems were divided by 21, related diseases and health problems were combined into classes, for example, according to the principle of systems affected by a group of coded diseases.

How to decipher the diagnosis

In order for a diagnosis, knowing its encoding according to ICD10, you need to understand the principle of the hierarchy of diseases according to this system. Classes in it are indicated by capital letters of the Latin alphabet (for example, the capital letter “I” denotes the ninth class of the ICD10, which codes for diseases of the circulatory system). This is followed by a two-digit numeric code designating a specific disease of this class (for example, the code "I11" denotes hypertension with a predominant heart lesion). This is followed by a third numerical character, separated from the main one, indicating the type of disease or the presence or type of its complications (for example, the code "I11.0" is hypertension with a primary lesion of the heart with congestive heart failure).4

There are classifiers used in medical institutions for coding and diagnoses. The Russian-language version is released in three volumes. In the first two volumes, codes are printed for all diseases, grouped into classes, which are arranged in the order of the Latin alphabet. The third volume contains a list of diagnoses in the language, arranged in alphabetical order, indicating the ICD code. There are also electronic versions with a search function, with the help of which any person, knowing the ICD10 diagnosis code, can find its transcript, even if he had not even heard of anything like this before. Electronic versions are distributed on CD to health professionals, but are now available on the Internet, making them accessible to almost everyone.

The use of such a classification of diagnoses greatly simplifies the work of doctors, and for clarification, the patient can always contact his treating specialist or independently find the diagnosis code in the classifier.

Sick leave is a document of strict accountability. Its design is strictly regulated by the relevant Rules and Law. The disease in the document is not written in words, it is indicated in the form of a digital code. Is it possible to decipher it, where to find information, more on this later in the article.

What does the disease code on the sick leave mean?

The disease code is deciphered as the reason for the employee to be on sick leave. The code means not only the diagnosis of the disease, but also other circumstances - absence due to the care of a child or a close relative, treatment in a sanatorium, etc. Coding information helps to reproduce it more accurately to the personnel department and the accountant of the enterprise, for the correct accounting of the employee's time and accrual disability payments.

The disease code has several levels:

Basic - indicates the main cause of disability. It consists of two parts of digital values. First - the national encoding of the disease, is affixed in the form of two Arabic numbers - 01, 02, 03, etc. Second part, represents the international system of records according to the adopted ICD-10 system. The inclusion and mandatory completion of the second part of the coding in the document makes it possible to provide it to international companies, and for a doctor - to fill out only one form;
Additional cipher. It indicates designations if, for example, an injury was received by an employee while intoxicated. In this case, the benefit payable is reduced;
Family connection. It is indicated if the sick leave was for the care of a child or relative.

Other additional code values carry information about the patient's compliance with the regime of visits to the doctor, the extension of the hospital day off and other information for the accounting and personnel departments of the enterprise.

Is it possible to find out the disease by the sick-list code?

The Constitution of the Russian Federation guarantees the inviolability of personal life. Health information also refers to the privacy of citizens.

The coding of information about the disease was adopted with the aim of:

Ensure the inviolability of personal information about the state of health of citizens. The cipher carries only general typical information, without specifying the type of illness, its form, etc. information;
For the convenience of recording the time of employees. It is difficult to make out the doctor's handwriting, the encoding makes it easier for the personnel and accounting department to read the sheet and perceive the information;
Saving paper and time to fill out the sheet.

The sick leave cause code indicates a generalized type of reason for an employee's absence from work. On the sheet, there is also a place for an additional cipher, which indicates, for example, a violation of the regime by an employee, an injury while intoxicated, and other points. The decoding can be found in the relevant Order of the Ministry of Health of the Russian Federation.

How to find out the disease by the code on the sick leave - transcript

The decoding of the disease code is in the corresponding document. The code is affixed by the attending physician, it is worth knowing that, # 14 and 15, can only be affixed with the written permission of the patient. Disease Code 01 stands for Disease. This name hides the most common infectious diseases, colds, SARS, etc.

What does the disease code 01 mean on the sick leave?

The diagnosis of the disease in the sick leave is coded according to the national and international system. Disease code 01 refers to the national coding system. This cipher means Disease. This is the most common code; infectious colds, SARS, and seasonal colds are encrypted under it.

How is sick leave paid for disease code 01?

When calculating benefits for temporary disability due to a general illness, they are guided by the obligatory condition is the social health insurance of the employee, since payments for temporary disability are provided from the compulsory insurance fund.

When calculating take:

Average earnings for the last two years, while the amount should not be higher than the established insurance base. Its size must be checked, as it changes every year. Based on the average earnings for two years, the average daily earnings are calculated to determine the amount of the allowance;
When calculating the amount of the daily allowance, the interest rate established, depending on the insurance period of the employee, is taken into account from the average earnings;
100% - experience of 8 or more years;
80% — from 5–8 years;
60% - experience less than 5 years.

The amount payable is calculated by multiplying the daily allowance by the number of disabled days. The amount payable in the document fits with personal income tax.

The disease code is incorrectly indicated on the sick leave, what should I do?

According to the rules for issuing this type of medical document, corrections of errors when filling out are possible only on the part of the employer. This means that if the doctor incorrectly indicated the code of the disease in the document, and this error was discovered, you must contact the doctor so that he reissues the form . If the attending physician refuses to do this, it is necessary to contact the head physician. The old sheet must be returned to the doctor, so it is important to keep it and provide it to the clinic. An incorrectly executed form by the doctor is written off according to the rules of the workflow.