CLASSIFICATION OF MEDICAL RECORDS.pptx

classification of health record

1. CLASSIFICATION OF MEDICAL RECORDS PRINCE KHANDELWAL

2. INTRODUCTION Medical records, also known as health records or medical charts, are comprehensive documents that contain a patient's health information and medical history. These records serve as a crucial component of the healthcare system, facilitating communication among healthcare providers, supporting patient care, and documenting the course of a patient's medical journey. Healthcare providers rely on medical records to make informed decisions about diagnosis, treatment, and ongoing care.

3. CLASSIFICATION Medical Records are classified as given below :- Coding System Indexing System

4. CODING SYSTEM Medical record coding is the process of assigning standardized codes to diagnoses, procedures, and other medical services in order to ensure accurate and consistent documentation and billing.  One of the most widely used coding systems in healthcare is the International Classification of Diseases (ICD) system, which is used to code diagnoses and inpatient procedures. Another important coding system is the Current Procedural Terminology (CPT) system, which is used to code outpatient procedures and services.

5. 1. ICD SYSTEM   The World Health Organization (WHO) created this internationally used code. The classification system is largely used for the purpose of health recording and data collection, among other uses. These codes can classify symptoms, diseases, illnesses, and causes of death.  The ongoing development of ICD-11 aims to address limitations in ICD-10, providing a more comprehensive and modernized system. ICD is used globally, ensuring a common language for health information.

6. CPT System The Current Procedural Terminology (CPT) is a system of medical coding maintained by the American Medical Association (AMA). It is widely used in the United States to describe medical, surgical, and diagnostic services provided by healthcare professionals.

7. Coding of CPT Numeric Codes: CPT codes are numeric and typically consist of five digits. Code Sections: Organized into sections, each representing a category of medical services. Evaluation and Management (E/M): Codes for office visits, consultations, and other evaluation and management services. Surgery: Codes for surgical procedures. Radiology: Codes for radiological procedures. Pathology and Laboratory: Codes for laboratory tests and procedures. Medicine: Codes for various medical services not included in other sections.

8. Indexing System Medical record indexing is a systematic method of organizing and storing patient records to ensure efficient retrieval and management. Several indexing systems are used in healthcare settings to categorize and locate patient information. Types:- Numeric Filing System: Patients are assigned a unique numeric identifier, and records are arranged in numerical order.

9. CONT… Alphabetic Filing System: Patients' last names are used as the primary sorting criterion, and records are arranged alphabetically. Terminal Digit Filing System: Similar to numeric filing, but the numbers are arranged in reverse order (last two digits, then the middle two, and finally the first two). Subject or Category Filing System: Records are grouped by subject or category, such as medical specialty or type of service.

10. CONT… Chronological Filing System: Orders records based on the date of service or entry. Problem-Oriented Medical Record (POMR) Indexing: Focuses on organizing records around specific medical problems or diagnoses.