الدرس العملي الأول في الترميز الصحي د صديق الحكيم

Clinical coders in practice

The basic task of a clinical coder is to classify medical and health care concepts using a standardised classification. Most clinical coders are employed in coding inpatient episodes of care However, mortality events, outpatient episodes, general practitioner visits and population health studies can all be coded.

Clinical coding has three key phases

: a) Abstraction; b) Assignment; and c) Review^]

 Abstraction

The abstraction phase involves reading the entire record of the health encounter and analysing the information to determine what condition(s) the patient had, what caused it and how it was treated. The information comes from a variety of sources within the medical record, such as clinical notes, laboratory and radiology results, and operation notes.

 Assignment

The assignment phase has two parts: finding the appropriate code(s) from the classification for the abstraction; and entering the code into the system being used to collect the coded data.

Review

Reviewing the code set produced from the assignment phase is very important. Clinical coder must ask themselves, "does this code set fairly represent what happened to this patient in this health encounter at this facility.

" By doing this, clinical coders are checking that they have covered everything that they must, but not used extraneous codes. For health encounters that are funded through a case mix mechanism, the clinical coder will also review the diagnosis-related group to ensure that it does fairly represent the health encounter.