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Módulo 1 – Terminología Médica

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Módulo 1 – Terminología Médica Catalogación en la fuente, biblioteca sede de la OPS Organización Panamericana de la Salud. Curso virtual para codificadores de información médica. Tomo 1 Washington, DC: 2017. 1. CIE-10. 2. Educación a distancia 3. Instrucción por medios virtuales. 4. América Latina. 5. Región del Caribe. 6. Sistemas de Información de Salud. 7. Red Latinoamericana y del Caribe para el Fortalecimiento de los Sis temas de Información de Salud (RELACSIS) 8. Centro Mexicano de Clasificación de Enfermedades (CEMECE). 9. Centro Argentino de Clasificación de Enfermedades (CACE). 10. Centros Colaboradores para la familia de clasificaciones internacionales de la OPS-OMS. ISBN y Clasificación e n trá mite (Esta versión tiene carácter preliminar. Se rue ga NO re p rodu ci r.) © Organización Panamericana de la Salud, 2014. Todos los derechos reservados. La Organización Panamericana de la Salud dará consideración a las solicitudes de autorización para rep rod u ci r o tradu ci r, ín te gramen te o en pa rte , alguna de sus publicaciones . Las solicitudes deberán dirigirse al Departamento de Ges�ón del Conocimiento, Bioé�ca e Inves�gación (KB R), Organización Panamericana de la Salud, Washington, D.C., EE. UU. (www.paho.org/publications /copyright-fo rms ). La Unidad de Información y Análisis de Salud (HA) del Departamento de Enfermedades Transmisibles y Análisis de Salud (CHA), 525, 23th Street. (NW) Washington, DC 20037, ([email protected]) pod rá proporcionar información sobre cambios introducidos en la obra, planes de reedición, reimpresiones y traducciones ya disponibles. Las publicaciones de la Organización Panamericana de la Salud están acogidas a la protección prevista por las disposiciones sobre reproducción de originales del Protocolo 2 de la Convención Universal sobre Derecho de Autor. Reservados todos los derechos . Las denominaciones empleadas en esta publicación y la forma en que aparecen presentados los datos que con�ene no implican, por parte de la Secretaría de la Organización Panamericana de la Salud, juicio alguno sobre la condición jurídica de países, territorios , ciudades o zonas, o de sus autoridades, ni respecto del trazado de sus fronteras o límites. La mención de determinadas sociedades mercan�les o de nombres comerciales de ciertos productos no implica que la Organización Panamericana de la Salud los apruebe o recomiende con preferencia a otros análogos. Salvo error u omisión, las denominaciones de productos patentados llevan en las publicaciones de la OPS letra inicial mayúscula. Es ta publicación con�ene la opinión colec�va de un grupo internacional de especialistas y no representa necesariamente el criterio ni las polí�cas de la Organización Panamericana de la Salud. La Organización Panamericana de la Salud ha adoptado todas las precauciones razonables para verificar la información que figura en la presente publicación, no obstante lo cual, el material publicado se distribuye sin garan�a de ningún �po, ni explícita ni implícita. El lector es responsable de la interpretación y el uso que haga de ese material, y en ningún caso la Organización Panamericana de la Salud podrá ser considerada responsable de daño alguno causado por su u�lización. Diseño gráfico: Equipo de producción y comunicación RELACSIS. 2 Contenidos Tomo 1 4 Presentación. 5 Fundamentos y características. 6 Estructura curricular. 13 Módulo 1 – Capacitación a distancia. 25 Módulo 2 – Terminología médica. Tomo 2 212 Módulo 3 - Generalidades de la Clasificación Internacional de Enfermedades (CIE) 220 Módulo 4 Estructura básica de la CIE-10 261 Módulo 5. El diagnóstico y su codificación 283 Módulo 6 Reglas y orientaciones para el registro y la codificación de la mortalidad 350 Módulo 7. Reglas y orientaciones para el registro y la codificación de la morbilidad 379 Módulo 8. Presentación estadística 395 Bibliografía 3 Presentación Este Curso ha sido desarrollado por la Red Latinoamericana y del Caribe para el Fortalecimiento de los Sistemas de Información en Salud (RELACSIS), en alianza con la Organización Panamericana de la Salud/Organización Mundial de la Salud (OPS/OMS) y MEASURE Evaluation, con el Centro Mexicano de Clasificación de Enfermedades y Centro Colaborador para la Familia de Clasificaciones Internacionales de la OMS en México (CEMECE) y con el Centro Argentino de Clasificación de Enfermedades y Centro Colaborador para la Familia de Clasificaciones Internacionales (OPS/OMS) en Argentina (CACE). El contenido conceptual, diseño y coordinación estuvo a cargo de Amanda Navarro y Adriana Orellano, con la colaboración en la edición del material de Manuel Yañez. El grupo de trabajo que elaboró la propuesta estuvo coordinado por Alejandro Giusti. Se agradece el aporte de las Dras. Martha Mazas, María López De Neira y María Laura Martínez integrantes del CACE, por la elaboración del Módulo de Terminología Médica (Módulo de estudio 2). Nuestro agradecimiento al Lic. Alejandro Giusti y a la Dra. Patricia Ruíz por el apoyo permanente en la tarea realizada. Secretariado RELACSIS Alejandro Giusti (OPS) Beatriz Plaza (MEASURE/Evaluation) Patricia Ruiz (OPS) Responsable CEMECE Aline Jiménez (DGIS, Secretaría de Salud, México) Responsable CACE Elida Marconi (DEIS, MSP, Argentina) OPS en México Tamara Mancero 4 Fundamentos y Características Los Sistemas de Información en Salud se nutren de datos de distintos componentes, que los aportan con un objetivo muy claro: la toma de decisiones y la gestión en salud. Para que a los responsables de estas actividades, se les brinden datos fidedignos, es imprescindible que todo el camino recorrido por ese dato hasta convertirse en información, tenga un tratamiento correcto por parte de los distintos actores intervinientes. O sea, que la captura y tratamiento del dato sea ajustada a la realidad, para que la información obtenida sea uniforme, comparable y oportuna. Uno de los actores de relevancia en el proceso de elaboración de la información, es quien aplica la Clasificación Estadística Internacional de Enfermedades y Problemas Relacionados con la Salud. Décima Revisión (CIE-10); es decir, el codificador de la información médica. Para ello debe capacitarse con el fin de conocerla y utilizarla correctamente. Este es el sentido del Curso Virtual de Codificación de Información Médica con la Clasificación Estadística Internacional de Enfermedades y Problemas Relacionados con la Salud. Décima Revisión (CIE-10). Características: Ha sido diseñado en la modalidad de enseñanza a distancia (E- learning), a los fines de democratizar el acceso a la capacitación y posibilitar que personas de diferentes países tengan la misma oportunidad de realizarlo. Para ello se han utilizado los aportes que la tecnología brinda, colocándolo en el Entorno Regional de la Organización Panamericana de la Salud (OPS). • Cada participante poseerá un Nombre de Usuario (propio y único) como también una Contraseña para su ingreso. • La estructura del curso es modular. En ocho (8) Módulos de Estudio, se impartirán los conocimientos para la formación integral del codificador. • Cada uno de los Módulos (dentro del Entorno Virtual), está integrado por los siguientes bloques: o Estructura: consta de una Introducción, Objetivos e Índice del Módulo. o Contenido: es el desarrollo temático del Módulo. o Guías Prácticas: contienen ejemplos que el estudiante debe resolver y consultar su respuesta. o Presentaciones en Power Point. o Videoconferencia/videos, según los casos • Tutores: nexo fundamental entre el Entorno Virtual y los participantes. Son las personas preparadas para tal fin, cuya función es la de guiar, crear técnicas para facilitar el aprendizaje, orientar en la resolución de dudas, evaluar a los estudiantes y estar en permanente contacto con ellos. • Evaluación Final: para aprobar la capacitación quienes se capacitan deberán resolverla y obtener un puntaje determinado, el que será comunicado oportunamente • Constancia de aprobación de la capacitación: Les será entregada a aquellas personas que cumplan que todos los requisitos establecidos a la finalización del Curso. 5 Estructura Curricular Módulo 1 Nociones básicas sobre educación a distancia I - Formación y Capacitación • Capacitarse a lo largo de la vida • ¿Qué es la educación a distancia? • La educación a distancia en los tiempos de internet: los aportes de la tecnología educativa • La formación de codificadores II - Aprender a distancia • ¿Cómo organizar y planificar el tiempo de estudio? III - Estructura del curso de capacitación a distancia • Modalidad a distancia • Herramientas utilizadas en la modalidad IV - El docente Módulo 2 Terminología Médica I - Introducción a la anatomofisiología y la terminología médica • Sección I: Anatomofisiología y terminología médica • Sección II: Lista de prefijos y sufijos II - Terminología médica relacionada con los capítulos de la CIE-10 Capítulo I - Ciertas enfermedades infecciosas y parasitarias (A00-B99) . Organización en la CIE-10 . Ejemplos de enfermedades infecciosas y parasitarias Capítulo II - Tumores [neoplasias] (C00-D48) . Organización en la CIE-10 . Concepto de tumor . Clasificación de los tumores . Terminología médica relacionada con los tumores Capítulo III - Enfermedades de la sangre y de los órganos hematopoyéticos y ciertos trastornos que afectan el mecanismo de la inmunidad (D50-D89) . Organización en la CIE-10 . La sangre y sus funciones . Terminología médica relacionada con la sangre y órganos hematopoyéticos . Patologías más frecuentes de la sangre, de los órganos hematopoyéticos y de los trastornos de la inmunidad Capítulo IV - Enfermedades endocrinas,
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