Documentation and Coding in Family Medicine – a Proposal for Solution
DOI: 10.3238/zfa.2011.0400german translation / full article
Summary: Medical documentation primarily serves the management of clinical care of individual patients. Coding is not categorically necessary for this purpose. In contrast, medical classifications like the International Classification of Diseases (ICD) are intended for generating data to describe groups of patients for administrative, managerial or scientific purposes. A medical classification should be specific for the field it describes as well as for the applied use of the emerging data. To classify means inevitably to reduce information. The granularity of a classification does not meet the requirements of documentation for individual patients. A thesaurus makes individual documentation and classification possible at the same time. In Germany coding in medicine was introduced to control reimbursement. Now the aim was to use the data for balancing differing morbidity loads between health care insurances. Accordingly, morbidity can be quantified via the diagnostic rubrics of ICD-10. However, morbidity in family medicine might be better described by the suffering of patients (illness) than by defined disease concepts. Coding of reasons for encounter with an adequate classification like the International Classification of Primary Care (ICPC-2) is mandatory for this. The federal reimbursement agency and some family practitioners proposed a “translation” of ICPC-codes to ICD codes as an aid within the new German ambulatory coding directives. However, this seems unrewarding. Instead, a specific thesaurus coding for both classifications would be a better solution. Such a thesaurus is available in some other languages. It should be translated and tested for feasibility in the German setting.