Clinical Coding is “the translation of medical terminology as written by the clinician to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format” which is then both nationally and internationally recognised.
There is wide recognition in the National Health Service (NHS) of the importance of good quality Coded Clinical Data and the fundamental role it plays in the management of hospitals and services. The government’s introduction of a National Performance Framework has created a mechanism whereby NHS Trusts will be judged on accurate results. Clinical data must be accurately and consistently recorded to well defined national standards to enable it to be used for statistical analysis. Information drawn from accurate clinical coding better reflects the pattern of practice of clinicians and provides a sound basis for the decision making process. The use of tools such as Clinical Indictors pushes forward the need for accurately and consistently recorded clinical information. Such information should be produced as part of the regular activity within a hospital provider unit. Steps to ensure that this is the case should include audit of clinical coded data and the comprehensive training of those responsible for the classification of such information. Healthcare information at local and national level is crucial to support management, planning and monitoring of health services.
The aforementioned codes are used to support many functions within the Trust, both clinically and statistically. These functions include:
- Clinically – Clinical Governance, Clinical Audit, and Outcome and Effectiveness of Patient’s Care and Treatment.
- Statistically – Payment by Results, Cost Analysis, Commissioning, Aetiology Studies, Health Trends, Epidemiology Studies, Clinical Indicators and Casemix Planning.