Terms in oncology. Cancer disease

Every patient wants to know what happened to him, and therefore, first of all, he wants to hear from the doctor the name of his illness, the diagnosis. However, understanding the complex medical terms can be difficult. 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-forming element indicating a particular dysfunction of an organ or system. For example, the presence in the name of the Greek prefix “a” (before the vowels - “an”) means negation, the absence of some quality. These are diseases such as anemia("hema" - blood) - literally translated means "bloodlessness" (practically - "anemia"); asthenia(“stenos” - strength) - literally “powerlessness”, “general weakness”; atrophy("trophe" - nutrition) - lack of nutrition; arrhythmia- literally “no rhythm”, that is, any disturbance of the heart rhythm; anuria("urina" - urine) - "no urine", cessation of urination, etc.

If the name of the disease contains the Greek prefix “dis”, this means a disorder, difficulty in the function of one or another organ. The names of diseases such as dystrophy- eating disorders; dyskinesia(“kinesis” - movement) - a violation of the contractile function of the digestive organs; dystonia(“tone” - tension) - a violation of the nervous regulation of vascular tone; dysbacteriosis("bacterion" - rod) - a violation of the biological balance between pathogenic and beneficial bacteria in the intestine; dysentery(“enteron” - intestine) - literally means “intestinal disorder”, etc.

When the name ends in “-itis,” the disease is usually inflammatory in nature. For example, arthritis("arthron" - joint) - inflammatory disease of the joint; gastritis(“gaster” - stomach) - inflammatory disease of the gastric mucosa; dermatitis("dermis" - skin) - inflammation of the skin; mastitis(“mastos” - breast) - inflammation of the mammary gland; nephritis(“nephros” - kidney) - 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 word-forming element “-oma”, meaning “tumor”. For example, angioma("angion" - vessel) - vascular tumor; myoma(“mios” - muscle) - tumor of muscle tissue; nephroma- malignant kidney tumor, etc.

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

Often the name of the disease indicates its main clinical symptom. For example, the presence of the word-forming 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(“hema” - blood and “philia” - tendency) - predisposition to bleeding; schizophrenia("schizo" - splitting, splitting and "fren" - soul, mind, reason) - split personality; haemorrhoids("hema" - blood and "roa" - outflow) - discharge of blood, bleeding; hypertension(“hyper” - above, above and “tonos” - tension) - increased tension in the blood vessels; angina(“ango” - soul) - suffocation; scarlet fever(“scarlatum” - bright red tissue) - redness of the mucous membrane of the oropharynx; stroke(“stroke” - blow) - characterizes the sudden onset of the disease, etc.

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

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

There are also more complex names. For example, myocardial dystrophy("myos" - muscle, "cardia" - heart, "dystrophe" - nutritional disorder) - 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 carrier (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 learn that the main pathological process of this disease is inflammation of the brain (“encephalon” means brain, and the ending “-itis” 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 essence. 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 is known, the basis of this disease is an increase in intraocular pressure.

The name of such a disease as "gonorrhea", the characteristic symptom of which is purulent discharge. But when the Roman physician Galen in the 2nd century AD. e. proposed this name, they believed that the essence of the disease lies in the leakage of seminal fluid: translated from Greek, “gonorrhea” means “ejaculation” (“gonos” - seed and “roe” - discharge). And although it was later found that pus is released in this case, the original name remained.

The occurrence of a disease such as "hysteria", Ancient Greek doctors associated it with disorders of the uterus. Hence the name "hysteria", derived from the Greek. "hystera" - uterus. But even after it was proven that the symptoms characteristic of this disease depend on a disorder of the nervous system, the term “hysteria” continues to be used to designate a neuropsychic 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 “malya aria” - bad air). And although the true reason for its occurrence was later revealed, the old name has been preserved to this day.

What does sick leave mean? With the help of a sick leave certificate, an illness, injury or other physiological problem of an employee is registered. The form is sometimes called differently - a sheet of temporary incapacity for work. It is allowed to be prescribed only by 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 enterprise administration within the established time frame.

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

Is the diagnosis written on the sick leave certificate? 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 associated with sick leave payments. That's why there's honey in everything. Institutions forms are received directly through FSS branches. The sheets are marked with serial numbers, 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 a black pen. Entries must be placed exactly within the boundaries of the 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 should not cross out, sign, or otherwise change the completed form.

Sample of a completed sick leave certificate:

If you need to change information, 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 is crossed out.

Then you should sign and date it, recording the fact of corrections. We also recommend that you read the article, from which you will learn about inaccuracies that FSS employees will not pay attention to.

The form must be filled out by two people: the doctor and the employer. The doctor is responsible for completing sections 1 and 3. The employer, in turn, is for the second. It should be taken into account that the FSS carries out quality control and conducts random checks. In the future, the Foundation plans to switch completely to an electronic sick leave system, which will further simplify the control task.

When registering/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 side of the sheet you can always find instructions for filling out, as well as a decoding of all codes.

Registration procedure

There are three people involved in registration: the doctor, the employer and the employee. An employee becomes ill and goes to a medical facility. The doctor must diagnose the patient's disease and health condition. Based on this, the doctor determines the duration of sick leave and enters it into the form. To do this, use the corresponding unified codes (detailed explanation below). Then he indicates the following information about the patient:

Date of Birth;
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 doctor must also indicate the name, address and registration number of his medical institution. After this, 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 completed by the doctor to the administration at the place of work. The employer fills out information regarding payment calculations and information about his company:

Name of organization - 29 cells are allocated, one empty cell must be left between words;
Type of work (main or part-time);
Registration number in the Social Insurance Fund (enterprise);
Subordination code;
Employee number (identification);
Fear. number;
Payment terms;
Fear. employee experience;
Avg. earnings;
Full name of the head. accountant and company manager;
Amount of payments - indicate three amounts: from the employer, from the Fund and the final amount (due to the employee).

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

Explanation of the fields on the sick leave:

The employee is also a participant in the registration process, but he practically does not fill out anything. All he needs to do is consult a doctor in a timely manner and obtain a certificate of incapacity for work. Then it is necessary (within 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 can be two-digit or three-digit (starting from zero). With the help of such a flexible system, all reasons for incapacity for work/issue of sick leave are coded. There are 15 main causes of disability(diseases), let's figure out what the codes on the sick leave mean, what disease and diagnosis is hidden behind it, and let's start deciphering them:

“01” - disease, the most common case, especially during influenza epidemics;
“02” - domestic injury, that is, damage to the body received outside of work/workplace;
“03” - quarantine, indicates the need for quarantine, typical for infectious diseases, for example, tuberculosis;
“04” is a work injury, but the correct name would be “work accident”;
“05” - the onset of disability due to pregnancy and childbirth;
“06” - prosthetics, which (for medical reasons) can only be performed in a hospital;
"07" - prof. disease, as well as exacerbation of prof. diseases, especially typical for industries with hazardous 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” is a disease from the list of social services. significant diseases, the list is approved by Government Decree N715. These include, in particular, tuberculosis, hepatitis, HIV, diabetes, oncology;
“12” - the reason is the illness of a child under 7 years old, the need for additional care;
“13” - caring for a disabled child;
“14” - cancer in a child or a post-vaccination complication;
“15” – HIV infection in a child.

Points “14” and “15” are noted on 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. They are incremental in nature, giving more detail if needed, and they start with the number “0.” There are five such designations in total:

“017” - indicate if the treatment took place in a special facility. sanatoriums;
“018” - undergoing sanatorium-resort treatment due to an industrial injury;
“019” – treatment in a clinic at a university/institute;
"020" - additional holiday for labor and finance;
“021” - noted if the disease/injury was caused by alcohol and drug use.

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

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

“31” - noted 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 sick leave);
“36” - the patient arrived (at the appointment) healthy and able to work.

In addition to codes for causes of disability, there are so-called ICD (International Classification of Diseases) codes.

The latest version is ICD-10, the tenth edition of this classification. The doctor on sick leave also notes the disease according to the ICD system. There are 22 classes of diseases in total. They are designated from "A00" to "Z100". The ICD is already completely medical information.

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

Conclusion A sick leave certificate is required when registering an employee’s temporary disability. In 2011, in order to optimize document flow and reduce FSS costs, 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.

An alphanumeric combination that the doctor put in his medical report instead of a clear, detailed diagnosis? And it’s not just a matter of curiosity - it’s just that many people are used to being in control of the situation, and the unknown doesn’t contribute much 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 into 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.

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

There are classifiers used in medical settings for coding and diagnoses. The Russian-language version was released in three volumes. The first two volumes contain codes 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 decoding, even if he has never even heard of anything like this before. Electronic versions are distributed on disk to health care workers, but they can now be found 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 their treating specialist or independently find the diagnosis code in the classifier.

A sick leave certificate is a document of strict accountability. Its registration is strictly regulated by the relevant Rules and Law. The disease is not written in words in the document; it is indicated as a digital code. Is it possible to decipher it, where to find information, this will be discussed in more detail later in the article.

What does the disease code on a sick leave mean?

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

The disease code has several levels:

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

Other additional code values carry information about the patient’s compliance with doctor’s visits, extension of sick leave and other information for the accounting department and human resources department of the enterprise.

Is it possible to recognize a disease by sick leave code?

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

Coding of information about the disease was adopted with the aim of:

Ensure the inviolability of personal information about the health status of citizens. The code carries only general typical information, without specifying the type of illness, its form, etc. information;
For the convenience of tracking employee time. The doctor’s handwriting is difficult to decipher; the encoding makes it easier for the HR and accounting departments to read the sheet and perceive the information;
Saves paper and time to fill out the sheet.

The code for the cause of illness on a sick leave certificate indicates a generalized type of reason for an employee’s absence from work. On the sheet, there is also space for an additional code, which indicates, for example, violation of the employee’s regime, 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 recognize a disease by code on a sick leave certificate - explanation

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

What does disease code 01 mean on a sick leave certificate?

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

How is sick leave paid for with disease code 01?

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

When calculating take:

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

The amount payable is calculated by multiplying the daily benefit by the number of days of incapacity. The amount to be paid is included in the document with personal income tax.

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

According to the rules for preparing 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 disease code in the document, and this error was discovered, you need to contact the doctor to reissue the form . If the attending physician refuses to do this, you must contact the head physician. The old sheet must be returned to the doctor, so it is important to save it and provide it to the clinic. An incorrectly completed form on the part of the doctor is written off according to the rules of document flow.