Coding of clinical items

  • primary goal: to improve clinical functionality and value
  • secondary goal: to enable secondary use of the data

  • narrative is the primary data
  • attached codes are secondary in nature
  • attached codes can be considered a "translation" of the narrative just like into another language
  • coding systems are in 99.9% of cases classifications
  • items useful to attach codes to:
    • Reason for Encounter (ICPC-2)
    • Outcome/Assessment of Encounter (ICPC-2)
    • Episode (ICPC-2, ICD-10)
    • Health Issue (ICPC-2, ICD-10)
    • medications/substances/vaccines (ATC)
    • test result types (LOINC)
    • French specific General Practice classification and clinical codification helper : eDRC (free database, specifications written, apps can be checked by this scientific society)

  • it can be useful to allow linking of
    • several ICD-10 to one health issue/episode
    • both ICD-10 and ICPC-2 to the same episode/issue

  • issue/encounter
    • same issue/episode description should be coded consistently
    • therefore use the .description as the key into a clin.coded_term table
    • thus, if .description changes, the code association is broken (which is good) automatically
    • if a .description is used that had been coded previously, it is automatically coded, too
    • if the codes associated with a description are changed, all uses of that description are automatically adjusted
    • clin.coded_term can contain several distinct codes from several coding systems for each description (one row has one code-system-term association)

--- This topic: Gnumed > WebHome > DevelopmentMain > DevelopmentReference > ClinicalCoding
Topic revision: 28 Jun 2010, KarstenHilbert
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