Editorials

Future of clinical coding

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2875 (Published 26 May 2016) Cite this as: BMJ 2016;353:i2875
  1. Stephen Andrew Spencer, deputy director of admissions
  1. Keele University Medical School, Keele, Staffordshire ST5 5BG, UK
  1. s.a.spencer{at}keele.ac.uk

Clinical data to improve clinical care

Clinical coding is used to classify the diagnosis and treatment of every inpatient for entry into a national data repository. The data are used for various purposes, mostly administrative. The system relies on the expertise of clinical coders, who extract data from largely unstructured notes using complex rules and a book of codes. The classification systems used in the UK are the international classification of diseases (ICD-10) for symptoms and diagnoses1 and the OPCS classification (OPCS-4) for procedures.2

This system has served the health service well since 1989, but the implementation of electronic patient records will require a radical change.3 Clinicians using electronic records will enter clinical data at the time of patient contact and are therefore in a good position to undertake clinical coding. In fact, it will become a professional responsibility because the data will be needed not just for administrative …

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