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Related Experiment Videos

General practice medical records: is coding appropriate?

M C Ireland1, B G Regan

  • 1Discipline of General Practice, Faculty of Medicine and Health Sciences, University of Newcastle, University Drive, Callaghan, New South Wales, 2308 Australia.

Medinfo. MEDINFO
|January 1, 1995
PubMed
Summary
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Coding in general practice aids medical research and statistics by standardizing terminology. While traditionally post-consultation, electronic records may increase its use for individual general practitioners (GPs).

Area of Science:

  • Health Informatics
  • General Practice
  • Medical Record Keeping

Background:

  • Coding in general practice has historically supported medical research and health statistics collection.
  • Current coding practices often occur post-consultation by individuals not present during patient encounters.
  • The variability and free-text nature of traditional paper-based general practice records present challenges for coding.

Purpose of the Study:

  • To explore the relevance and potential place of coding for individual general practitioners (GPs) beyond research and statistics.
  • To assess the impact of increasing computerization and electronic health records on coding practices in general practice.

Main Methods:

  • Discussion and analysis of current coding practices in general practice.

Related Experiment Videos

  • Consideration of the characteristics of paper-based versus electronic health records.
  • Exploration of the implications of electronic records for standardized data entry and coding.

    • Main Results:

    • Paper-based records, with their free-form text and variability, are difficult to code.
    • The increasing adoption of electronic health records is likely to enhance the feasibility and potential for universal coding.
    • Future trends may involve pressure for GPs to adopt standardized formats and coding systems.

    Conclusions:

    • Coding's role in general practice is evolving with technological advancements.
    • Electronic health records present opportunities for more integrated and consistent coding.
    • The future may see increased standardization and coding adoption by individual GPs.