Coding of procedures documented by general practitioners in Swedish primary care-an explorative study using two procedure coding systems

BMC Family Practice

Research Article

Mikael Nyström¹  Sabine Koch²  Maria Hägglund²  Lars-Erik Strender³  Anna Vikström³  Gunnar H Nilsson³  Ulf Lindblad⁴  Per Hjerpe⁵ 

[1] Department of Biomedical Engineering, Linköpings University, SE-581 85, Linköping, Sweden;Department of Learning, Informatics, Management and Ethics, Health Informatics Centre-(HIC), Karolinska Institutet, SE-171 77, Stockholm, Sweden;Department of Neurobiology, Care Sciences and Society, Center for Family and Community Medicine, Karolinska Institutet, SE-141 83, Huddinge, Sweden;Department of Public Health and Community Medicine/Primary Health Care, the Sahlgrenska Academy at the University of Gothenburg, Sweden;R&D Centre, Skaraborg PC, Skövde, Sweden 5 Social Epidemiology, Department of Clinical Sciences, Faculty of Medicine, Lund University, Sweden;

关键词: Primary Care;    Health Care Professional;    Procedure Code;    Electronic Patient Record;    International Statistical Classification;   

DOI  :  10.1186/1471-2296-13-2

 received in 2011-05-23, accepted in 2012-01-09,  发布年份 2012

来源: Springer

【 摘 要 】

BackgroundProcedures documented by general practitioners in primary care have not been studied in relation to procedure coding systems. We aimed to describe procedures documented by Swedish general practitioners in electronic patient records and to compare them to the Swedish Classification of Health Interventions (KVÅ) and SNOMED CT.MethodsProcedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed.Results417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health Interventions category and 4.3% could not be coded with any SNOMED CT concept. 206 procedure-concept/category pairs were assessed as a complete match in SNOMED CT compared to 10 in the Classification of Health Interventions.ConclusionsProcedures documented by general practitioners were present in nearly all electronic patient record entries. Almost all procedures could be coded using SNOMED CT.Classification of Health Interventions covered the procedures to a lesser extent and with a much lower degree of concordance. SNOMED CT is a more flexible terminology system that can be used for different purposes for procedure coding in primary care.

【 授权许可】

CC BY   
© Vikström et al; licensee BioMed Central Ltd. 2012