Charity Melanie J, French Simon D, Forsdike Kirsty, Britt Helena, Polus Barbara, Gunn Jane
General Practice and Primary Health Care Academic Centre, University of Melbourne, 200 Berkeley St, Carlton, VIC 3010, Australia.
Chiropr Man Therap. 2013 Jan 14;21(1):4. doi: 10.1186/2045-709X-21-4.
Typically a large amount of information is collected during healthcare research and this information needs to be organised in a way that will make it manageable and to facilitate clear reporting. The Chiropractic Observation and Analysis STudy (COAST) was a cross sectional observational study that described the clinical practices of chiropractors in Victoria, Australia. To code chiropractic encounters COAST used the International Classification of Primary Care (ICPC-2) with the PLUS general practice clinical terminology to code chiropractic encounters. This paper describes the process by which a chiropractic-profession specific terminology was developed for use in research by expanding the current ICPC-2 PLUS system.
The coder referred to the ICPC-2 PLUS system when coding chiropractor recorded encounter details (reasons for encounter, diagnoses/problems and processes of care). The coder used rules and conventions supplied by the Family Medicine Research Unit at the University of Sydney, the developers of the PLUS system. New chiropractic specific terms and codes were created when a relevant term was not available in ICPC-2 PLUS.
Information was collected from 52 chiropractors who documented 4,464 chiropractor-patient encounters. During the study, 6,225 reasons for encounter and 6,491 diagnoses/problems were documented, coded and analysed; 169 new chiropractic specific terms were added to the ICPC-2 PLUS terminology list. Most new terms were allocated to diagnoses/problems, with reasons for encounter generally well covered in the original ICPC 2 PLUS terminology: 3,074 of the 6,491 (47%) diagnoses/problems and 274 of the 6,225 (4%) reasons for encounter recorded during encounters were coded to a new term. Twenty nine new terms (17%) represented chiropractic processes of care.
While existing ICPC-2 PLUS terminology could not fully represent chiropractic practice, adding terms specific to chiropractic enabled coding of a large number of chiropractic encounters at the desired level. Further, the new system attempted to record the diversity among chiropractic encounters while enabling generalisation for reporting where required. COAST is ongoing, and as such, any further encounters received from chiropractors will enable addition and refinement of ICPC-2 PLUS (Chiro). More research is needed into the diagnosis/problem descriptions used by chiropractors.
在医疗保健研究过程中通常会收集大量信息，这些信息需要以一种便于管理和清晰报告的方式进行整理。整脊观察与分析研究（COAST）是一项横断面观察性研究，描述了澳大利亚维多利亚州整脊治疗师的临床实践。为了对整脊治疗过程进行编码，COAST使用国际初级保健分类（ICPC - 2）以及PLUS全科临床术语来对整脊治疗过程进行编码。本文描述了通过扩展当前的ICPC - 2 PLUS系统开发一种用于研究的整脊专业特定术语的过程。
编码人员在对整脊治疗师记录的治疗过程细节（治疗原因、诊断/问题和护理过程）进行编码时参考ICPC - 2 PLUS系统。编码人员使用悉尼大学家庭医学研究单位（PLUS系统的开发者）提供的规则和惯例。当ICPC - 2 PLUS中没有相关术语时，创建新的整脊专业特定术语和代码。
从52名整脊治疗师那里收集了信息，他们记录了4464次整脊治疗师与患者的接触。在研究期间，记录、编码和分析了6225个治疗原因以及6491个诊断/问题；169个新的整脊专业特定术语被添加到ICPC - 2 PLUS术语列表中。大多数新术语被分配到诊断/问题类别，治疗原因在原始的ICPC 2 PLUS术语中通常涵盖得较好：在治疗过程中记录的6491个（47%）诊断/问题中的3074个以及6225个（4%）治疗原因中的274个被编码为新术语。29个新术语（17%）代表整脊护理过程。
虽然现有的ICPC - 2 PLUS术语不能完全代表整脊治疗实践，但添加整脊专业特定术语能够在期望的层面上对大量整脊治疗过程进行编码。此外，新系统试图记录整脊治疗过程中的多样性，同时在需要时便于进行报告归纳。COAST研究仍在进行中，因此，从整脊治疗师那里收到的任何进一步的治疗过程信息都将有助于ICPC - 2 PLUS（整脊）的补充和完善。需要对整脊治疗师使用的诊断/问题描述进行更多研究。
