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General practice medical records: why code? Why classify?

H Britt1, N Beaton, G Miller

  • 1Department of General Practice, University of Sydney.

Australian Family Physician
|April 1, 1995
PubMed
Summary
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This paper explains the importance of coding and classifying clinical data in general practice computerised medical records. It was prepared for general practitioners following a workshop by the Information Management Steering Group.

Area of Science:

  • Health Informatics
  • General Practice Data Management

Background:

  • The Information Management Steering Group (IMSG) reviewed coding systems for general practice computerised medical records.
  • Past discussions have questioned the value of clinical data coding.

Purpose of the Study:

  • To outline the reasons for coding and classifying clinical data.
  • To disseminate this information to all general practitioners.

Main Methods:

  • A Coding Workshop was convened by the IMSG.
  • Review of available coding systems and their application in electronic health records.

Main Results:

  • Agreement among workshop participants on the need for a paper detailing the rationale for coding.
  • Identification of available coding systems for general practice.

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Conclusions:

  • Coding and classification of clinical data are essential for effective information management in general practice.
  • Dissemination of this information aims to improve understanding and adoption among practitioners.