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门诊神经学诊断编码:标准化实施的建议方案。

Outpatient neurology diagnostic coding: a proposed scheme for standardised implementation.

机构信息

Lancaster Medical School, Lancaster University, Lancaster, UK.

Department of Neurology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK.

出版信息

Pract Neurol. 2023 Aug;23(4):317-322. doi: 10.1136/pn-2021-003286. Epub 2023 Feb 20.

Abstract

Clinical coding uses a classification system to assign standard codes to clinical terms and so facilitates good clinical practice through audit, service design and research. However, despite clinical coding being mandatory for inpatient activity, this is often not so for outpatient services, where most neurological care is delivered. Recent reports by the UK National Neurosciences Advisory Group and NHS England's 'Getting It Right First Time' initiative recommend implementing outpatient coding. The UK currently has no standardised system for outpatient neurology diagnostic coding. However, most new attendances at general neurology clinics appear to be classifiable with a limited number of diagnostic terms. We present the rationale for diagnostic coding and its benefits, and the need for clinical engagement to develop a system that is pragmatic, quick and easy to use. We outline a scheme developed in the UK that could be used elsewhere.

摘要

临床编码使用分类系统为临床术语分配标准代码,从而通过审核、服务设计和研究促进良好的临床实践。然而,尽管住院活动必须进行临床编码,但门诊服务往往并非如此,而大多数神经科护理都是在门诊服务中提供的。英国国家神经科学咨询小组和英格兰 NHS 的“一次做对”倡议最近的报告建议实施门诊编码。英国目前没有标准化的门诊神经科诊断编码系统。然而,大多数普通神经科诊所的新就诊似乎可以用有限数量的诊断术语进行分类。我们介绍了诊断编码的原理及其益处,以及临床参与开发实用、快速和易于使用的系统的必要性。我们概述了在英国开发的一种方案,该方案可在其他地方使用。

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