Clinical Coding - Need and Definition
Consider the following scenario
3 doctors from 3 different departments are meeting for a cup of coffee late in the evening at the hospital cafeteria. They are discussing the 3 patients they have lost in the last few days.
The Medical Superintendent of the hospital walks in at that time.
The first doctor narrates about the young girl with Koch’s disease who had died in her ward. The second doctor discusses his patient with multi-drug resistant pulmonary tuberculosis (MDR Pulm Tb) who had died the previous night. The third doctor tells of his middle-aged male patient who had died of tuberculosis with massive hemoptysis.
All these deaths get recorded and then sent to the medical records department for data entry.
At the monthly death audit meeting in the Medical Superintendent’s office, the reports on the various causes of death in the hospital are read out.
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Total number of Tb deaths = 1
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The Medical Superintendent remembers his conversation with the doctors and knows there are more Tb deaths. So she asks the data analyst to search in the Excel sheet using the keyword ‘Tb’, the answer comes back as 1. She asks him to repeat the search but now with the search term as ‘Tuberculosis’, the answer still comes back as 1
Why is it that the 3 deaths due to Tb were not picked up by the hospital medical records department?
The computer can recognize deaths based on the search term provided.
So if the death certificates of 3 Tb cases are written in 3 different ways, there’s no way the computer would know.
This example stresses on the need to use a universal language that can be understood irrespective of the different terminologies used for the same disease by different healthcare professionals in the same or different settings — that is, the need to identify and assign a code for a particular disease — this is called ‘clinical coding’.
Clinical coding is defined as “the translation of diagnoses of diseases, health-related problems and procedural concepts from text to alphabetic/numeric codes for easy storage, retrieval, and uniformity of comparison and analyses”.
Definition of Clinical coding -
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e-MCCD M2U1LA2
By drkavya1
e-MCCD M2U1LA2
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