4.2 Clinical records and global diagnostic codes
Identifieur interne : 008598 ( Main/Exploration ); précédent : 008597; suivant : 0085994.2 Clinical records and global diagnostic codes
Auteurs : Prathip Phantumvanit [Thaïlande] ; Roger A. Monteil [France] ; Trevor Frank Walsh [Royaume-Uni] ; Francesca Ada Miotti [Italie] ; Peter Carlsson [Suède] ; Asterios Doukoudakis [Grèce] ; Christopher Fox ; Winfried Harzer [Allemagne]Source :
- European Journal of Dental Education [ 1396-5883 ] ; 2002-10.
Descripteurs français
- Wicri :
- topic : Codage, Technologie de l'information.
English descriptors
- KwdEn :
- Anomaly, Auxillary information, Base relationship, British society, Clinical notes, Clinical record, Clinical records, Codes table, Coding, Coding systems, Coloured area, Commun dent, Condylar hyperplasia, Core values, Data exchange, Deepest pocket, Dent, Dental arch relationship, Dental disorders, Dental education, Dental procedures, Dental records, Dental schools, Dentistry, Diagnostic codes, Diagnostic information, Family history, Gingival, Global, Global application, Global coding, Global coding system, Global communication, Health status, Information model, Information technology, Interdisciplinary focus, International classification, International organization, Language system, Large amounts, Last visit, Mandibular, Medical doctor, Medical history, Medication, Midline deviation, Mucogingival deformaties, Oral health, Oral health record, Recreational drugs, Regional differences, Sextant, Social history, Strategic decisions, Temporomandibular, Temporomandibular syndrome, Thematic network, Time frame, Unspecified anomalies, Unwanted reactions, World health organization.
- Teeft :
- Anomaly, Auxillary information, Base relationship, British society, Clinical notes, Clinical record, Clinical records, Codes table, Coding, Coding systems, Coloured area, Commun dent, Condylar hyperplasia, Core values, Data exchange, Deepest pocket, Dent, Dental arch relationship, Dental disorders, Dental education, Dental procedures, Dental records, Dental schools, Dentistry, Diagnostic codes, Diagnostic information, Family history, Gingival, Global, Global application, Global coding, Global coding system, Global communication, Health status, Information model, Information technology, Interdisciplinary focus, International classification, International organization, Language system, Large amounts, Last visit, Mandibular, Medical doctor, Medical history, Medication, Midline deviation, Mucogingival deformaties, Oral health, Oral health record, Recreational drugs, Regional differences, Sextant, Social history, Strategic decisions, Temporomandibular, Temporomandibular syndrome, Thematic network, Time frame, Unspecified anomalies, Unwanted reactions, World health organization.
Abstract
A clinical record should include the personal demographic details of the patient, health status, diagnostic information and management/treatment options. However, clinical records are of little use without effective filing and retrieving systems. Coding is therefore necessary to deal with large amounts of differing data and a global coding system could be effectively developed through the use of information technology. The aim of this section was to review the main existing vocabularies and coding systems and to examine ways of improving their global application. It was concluded that global diagnostic codes would be beneficial to the patient, to the profession and to those responsible for strategic decisions concerning the delivery of health care. Extant dental clinical codes are not accepted widely or applied universally. There is an urgent need to identify existing coding systems and to assess their utility and potential for global application. Every effort should be made to include existing codes in the development of a global coding system on which all specialist areas would need to agree. This would require the provision of an overarching interdisciplinary focus and funding should be made available for this development and its implementation.
Url:
DOI: 10.1034/j.1600-0579.6.s3.18.x
Affiliations:
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Le document en format XML
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<term>Clinical record</term>
<term>Clinical records</term>
<term>Codes table</term>
<term>Coding</term>
<term>Coding systems</term>
<term>Coloured area</term>
<term>Commun dent</term>
<term>Condylar hyperplasia</term>
<term>Core values</term>
<term>Data exchange</term>
<term>Deepest pocket</term>
<term>Dent</term>
<term>Dental arch relationship</term>
<term>Dental disorders</term>
<term>Dental education</term>
<term>Dental procedures</term>
<term>Dental records</term>
<term>Dental schools</term>
<term>Dentistry</term>
<term>Diagnostic codes</term>
<term>Diagnostic information</term>
<term>Family history</term>
<term>Gingival</term>
<term>Global</term>
<term>Global application</term>
<term>Global coding</term>
<term>Global coding system</term>
<term>Global communication</term>
<term>Health status</term>
<term>Information model</term>
<term>Information technology</term>
<term>Interdisciplinary focus</term>
<term>International classification</term>
<term>International organization</term>
<term>Language system</term>
<term>Large amounts</term>
<term>Last visit</term>
<term>Mandibular</term>
<term>Medical doctor</term>
<term>Medical history</term>
<term>Medication</term>
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<term>Mucogingival deformaties</term>
<term>Oral health</term>
<term>Oral health record</term>
<term>Recreational drugs</term>
<term>Regional differences</term>
<term>Sextant</term>
<term>Social history</term>
<term>Strategic decisions</term>
<term>Temporomandibular</term>
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<term>Clinical records</term>
<term>Codes table</term>
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<term>International classification</term>
<term>International organization</term>
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<term>Last visit</term>
<term>Mandibular</term>
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<term>Mucogingival deformaties</term>
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<term>Oral health record</term>
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<term>Sextant</term>
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<term>Temporomandibular syndrome</term>
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<front><div type="abstract" xml:lang="en">A clinical record should include the personal demographic details of the patient, health status, diagnostic information and management/treatment options. However, clinical records are of little use without effective filing and retrieving systems. Coding is therefore necessary to deal with large amounts of differing data and a global coding system could be effectively developed through the use of information technology. The aim of this section was to review the main existing vocabularies and coding systems and to examine ways of improving their global application. It was concluded that global diagnostic codes would be beneficial to the patient, to the profession and to those responsible for strategic decisions concerning the delivery of health care. Extant dental clinical codes are not accepted widely or applied universally. There is an urgent need to identify existing coding systems and to assess their utility and potential for global application. Every effort should be made to include existing codes in the development of a global coding system on which all specialist areas would need to agree. This would require the provision of an overarching interdisciplinary focus and funding should be made available for this development and its implementation.</div>
</front>
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