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Coding of procedures documented by general practitioners in Swedish primary care-an explorative study using two procedure coding systems

Vikstrom, Anna; Hagglund, Maria; Nystrom, Mikael; Strender, Lars-Erik; Koch, Sabine; Hjerpe, Per; Lindblad, Ulf LU and Nilsson, Gunnar H. (2012) In BMC Family Practice 13.
Abstract
Background: Procedures documented by general practitioners in primary care have not been studied in relation to procedure coding systems. We aimed to describe procedures documented by Swedish general practitioners in electronic patient records and to compare them to the Swedish Classification of Health Interventions (KVA) and SNOMED CT. Methods: Procedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed. Results: 417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health... (More)
Background: Procedures documented by general practitioners in primary care have not been studied in relation to procedure coding systems. We aimed to describe procedures documented by Swedish general practitioners in electronic patient records and to compare them to the Swedish Classification of Health Interventions (KVA) and SNOMED CT. Methods: Procedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed. Results: 417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health Interventions category and 4.3% could not be coded with any SNOMED CT concept. 206 procedure-concept/category pairs were assessed as a complete match in SNOMED CT compared to 10 in the Classification of Health Interventions. Conclusions: Procedures documented by general practitioners were present in nearly all electronic patient record entries. Almost all procedures could be coded using SNOMED CT. Classification of Health Interventions covered the procedures to a lesser extent and with a much lower degree of concordance. SNOMED CT is a more flexible terminology system that can be used for different purposes for procedure coding in primary care. (Less)
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author
organization
publishing date
type
Contribution to journal
publication status
published
subject
in
BMC Family Practice
volume
13
publisher
BioMed Central
external identifiers
  • wos:000300148600001
  • scopus:84855483664
ISSN
1471-2296
DOI
10.1186/1471-2296-13-2
language
English
LU publication?
yes
id
51bd461e-6c2c-4c23-93f8-2ee62fbf1ce3 (old id 2416035)
date added to LUP
2012-04-02 09:33:38
date last changed
2017-01-01 06:17:09
@article{51bd461e-6c2c-4c23-93f8-2ee62fbf1ce3,
  abstract     = {Background: Procedures documented by general practitioners in primary care have not been studied in relation to procedure coding systems. We aimed to describe procedures documented by Swedish general practitioners in electronic patient records and to compare them to the Swedish Classification of Health Interventions (KVA) and SNOMED CT. Methods: Procedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed. Results: 417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health Interventions category and 4.3% could not be coded with any SNOMED CT concept. 206 procedure-concept/category pairs were assessed as a complete match in SNOMED CT compared to 10 in the Classification of Health Interventions. Conclusions: Procedures documented by general practitioners were present in nearly all electronic patient record entries. Almost all procedures could be coded using SNOMED CT. Classification of Health Interventions covered the procedures to a lesser extent and with a much lower degree of concordance. SNOMED CT is a more flexible terminology system that can be used for different purposes for procedure coding in primary care.},
  author       = {Vikstrom, Anna and Hagglund, Maria and Nystrom, Mikael and Strender, Lars-Erik and Koch, Sabine and Hjerpe, Per and Lindblad, Ulf and Nilsson, Gunnar H.},
  issn         = {1471-2296},
  language     = {eng},
  publisher    = {BioMed Central},
  series       = {BMC Family Practice},
  title        = {Coding of procedures documented by general practitioners in Swedish primary care-an explorative study using two procedure coding systems},
  url          = {http://dx.doi.org/10.1186/1471-2296-13-2},
  volume       = {13},
  year         = {2012},
}