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Rajakumar.M,
Manager-Medical Records,
Aravind Eye Care System.
The number of people working in the health care field has increased tremendously. This fact, coupled with an increase in the number and kinds of health care specialists, makes it imperative that there should be clear communication about a patients condition. Use of standardized terminology to describe clinical progress and treatment procedures is one of the means for ensuring that all people involved in patient care have a common understanding of the patients disease. Numerous attempts have been made over the years to compile accurate descriptions and identifications of all known diseases. Prior to the nineteenth century, results of such attempts produced some rudimentary classification systems, .i.e., coding.
What is coding?
It is the translating of narrative descriptions of diseases, injuries and procedures into numeric codes. The coding process involves assigning numbers to disease and procedural terms. The principal source of coded information is the medical record. The face sheet lists final diagnosis and operations and is completed by the attending physician.
Classification of Diseases and Operations:
Classification of diseases and procedures may be defined as a system of categories to which morbid conditions are assigned according to some established criteria. All medical files of patients treated in both the outpatient and the inpatient department must be coded for diseases and operations.
Classification of diseases and operations is one of the most important functions of the medical records department. A well-organized department selects one of the best-suited International Classification Systems to code and index diseases and operations for the collection of morbidity and mortality information.
ICD & IDP
ICD & ICP refers to The International Classification of Diseases and The International Classification of Procedures. It permits systematic recording, analysing, interpretation, and comparison of morbidity and mortality data collected in different countries or areas and at different times. Based on the official version of WHOs 9th revision of ICD, the USA National Center for Health Statistics published the Clinical Modification of (ICD - 9CM) in 1978. In this version, diseases were further classified or sub classified for more specificity. The 10th version of ICD was published on 1993. WHO recommended the implementation of the ICD 10, effective as of 1994. This reference material gives the rules and regulations to be followed in coding and classifying the diseases according to morbidity and mortality data.
Purpose
Coding is done in order to group conditions and procedures that are similar for statistical tabulation. Medical and health statistics are generally used to
- Plan appropriate health services
- Classify patterns of disease in health care facility
- Forecast health needs of communities, region and nations
- Study epidemiology (incidence rates of diseases etc)
- Standardize reporting systems for easy assimilation
- Provide teaching material for medical education
- Evaluate health care with appropriate measures.
Manual indexing system:
An important function of the medical record department is the compilation of patient care data from medical records. This means that certain information about patient care was extracted from medical records and hand posted on ledger sheets or cards.
The disease conditions for which patients were treated were coded and then posted on a set of index cards, which comprised the disease index.{A disease index lists diseases and conditions according to the classification system or code numbers assigned by medical record department personnel.}
Similarly operations and treatment procedures were coded and posted on another set of cards form the operations index. {The operation index is comprised of a listing of surgical and procedural code numbers.}
A third set of cards contained the names of all physicians attached to a health facility and listed the names of every patient those physicians treated. The majority of facility personnel, often knew these three indexes.
While there are many manually maintained indexes still in existence, the trend is the increasing computerization of this activity. Hence Indexing manually means that disease and operation code numbers are entered by hand or posted on each appropriate disease or operative index cards.
Purpose
A physician or a medical staff committee might use the disease and operation indexes to retrieve medical records for the following purposes:
- To review previous cases of a given disease in order to provide insight into the management of current patients health problems.
- To test theories and compare data on certain diseases and/or treatments in order to conduct research and prepare scientific papers.
- To procure data on the utilization of hospital facilities and to establish a hospitals need for new equipment, beds, staff, etc., in various departments.
- To evaluate the quality of care in the hospital.
- To conduct epidemiological and infection control studies on the work environment.
In addition to physicians use of the indexes, numerous requests for patient care data are received from hospital administrators and authorized personnel, planning agencies, educational programs, and health care agencies and organizations. The disease and operation indexes are the most expensive indexes to maintain in the department. The indexing clerk must not only be a capable individual, but also extremely accurate in making the entries. Indexing systems may be effectively designed for manual entry of the data on index cards or for computerized entry into a data processing system.
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