General practice medical records: is coding appropriate?.
Codes in general practice have been used for some time to facilitate medical research and for the gathering of health statistics. Coding is used to standardize terminology and avoid ambiguity. In general practice, this coding has usually been done some time after the notes are recorded and often by a person not involved in the consultation. This has been necessary because most medical records are recorded on paper using natural language. Does coding have any place with the individual general practitioner (GP) if health statistics or medical research are not involved? General practice notes are extremely variable; they are a collection of free form text, diagrams, idiosyncratic, and standard abbreviations and are usually stored on paper and often include several summary pages. This type of record does not easily lend itself to coding. With the increasing use of computers, the electronic record will become more common and may eventually replace the paper record [1]. As this occurs, the possibility of universal coding will increase, and there may be some pressure for all GPs to record their notes in a standard format and/or use standard codes.
Ireland
M C
MC
Discipline of General Practice, Faculty of Medicine and Health Sciences, University of Newcastle, University Drive, Callaghan, New South Wales, 2308 Australia.
Regan
B G
BG
D003933:Diagnosis; D005194:Family Practice; D008487:Medical History Taking; D008499:Medical Records; D016347:Medical Records Systems, Computerized; D018875:Vocabulary, Controlled