What should we code in health records with the International Classification of Primary Care?

Detalhes bibliográficos
Autor(a) principal: Pinto, Daniel
Data de Publicação: 2014
Tipo de documento: Artigo
Idioma: por
Título da fonte: Repositórios Científicos de Acesso Aberto de Portugal (RCAAP)
Texto Completo: https://doi.org/10.32385/rpmgf.v30i5.11391
Resumo: In Portugal, family physicians use the International Classification of Primary Care (ICPC) for coding in their electronic health records. However, questions about the use of the classification in daily practice are common. This text aims to clarify what should be coded in health records. ICPC allows the coding of reasons for encounter, health problems, and the process of care. Users should avoid confusion of these terms with the headings “subjective”, “assessment” and “plan” in follow-up notes of the problem-oriented medical record. In daily practice, most users should limit themselves to the coding of health problems. Family physicians should focus on coding the main problems of the patient and maintaining a list of all problems
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spelling What should we code in health records with the International Classification of Primary Care?O que classificar nos registos clínicos com a Classificação Internacional de Cuidados Primários?ClassificationsProblem Oriented Medical RecordElectronic Health RecordPrimary Health Care.ClassificaçõesRegisto Médico Orientado por ProblemasRegisto de Saúde ElectrónicoCuidados de Saúde Primários.In Portugal, family physicians use the International Classification of Primary Care (ICPC) for coding in their electronic health records. However, questions about the use of the classification in daily practice are common. This text aims to clarify what should be coded in health records. ICPC allows the coding of reasons for encounter, health problems, and the process of care. Users should avoid confusion of these terms with the headings “subjective”, “assessment” and “plan” in follow-up notes of the problem-oriented medical record. In daily practice, most users should limit themselves to the coding of health problems. Family physicians should focus on coding the main problems of the patient and maintaining a list of all problemsEm Portugal, a Classificação Internacional de Cuidados Primários (ICPC) é utilizada pelos médicos de família para classificar os seus registos de saúde electrónicos. Porém, são frequentes as dúvidas acerca da aplicação da classificação no dia-a-dia. Este texto procura esclarecer os utilizadores quanto ao que deve ser classificado no registo clínico. A ICPC permite classificar motivos de consulta, problemas de saúde e procedimentos, devendo evitar-se a confusão com os campos subjectivo, avaliação e plano das notas de seguimento do registo médico orientado por problemas. Na prática diária, a maioria dos utilizadores deve limitar-se à classificação dos problemas de saúde. A manutenção das listas de todos os problemas e de problemas principais deve ser o principal foco de atenção dos médicos de família no que se refere à classificação.Associação Portuguesa de Medicina Geral e Familiar2014-09-01info:eu-repo/semantics/publishedVersioninfo:eu-repo/semantics/articleapplication/pdfhttps://doi.org/10.32385/rpmgf.v30i5.11391https://doi.org/10.32385/rpmgf.v30i5.11391Portuguese Journal of Family Medicine and General Practice; Vol. 30 No. 5 (2014): Revista Portuguesa de Medicina Geral e Familiar; 328-34Revista Portuguesa de Medicina Geral e Familiar; Vol. 30 Núm. 5 (2014): Revista Portuguesa de Medicina Geral e Familiar; 328-34Revista Portuguesa de Medicina Geral e Familiar; Vol. 30 N.º 5 (2014): Revista Portuguesa de Medicina Geral e Familiar; 328-342182-51812182-517310.32385/rpmgf.v30i5reponame:Repositórios Científicos de Acesso Aberto de Portugal (RCAAP)instname:FCCN, serviços digitais da FCT – Fundação para a Ciência e a Tecnologiainstacron:RCAAPporhttps://rpmgf.pt/ojs/index.php/rpmgf/article/view/11391https://rpmgf.pt/ojs/index.php/rpmgf/article/view/11391/11112Pinto, Danielinfo:eu-repo/semantics/openAccess2024-09-17T11:59:49Zoai:ojs.rpmgf.pt:article/11391Portal AgregadorONGhttps://www.rcaap.pt/oai/openaireinfo@rcaap.ptopendoar:https://opendoar.ac.uk/repository/71602025-05-28T18:51:55.260326Repositórios Científicos de Acesso Aberto de Portugal (RCAAP) - FCCN, serviços digitais da FCT – Fundação para a Ciência e a Tecnologiafalse
dc.title.none.fl_str_mv What should we code in health records with the International Classification of Primary Care?
O que classificar nos registos clínicos com a Classificação Internacional de Cuidados Primários?
title What should we code in health records with the International Classification of Primary Care?
spellingShingle What should we code in health records with the International Classification of Primary Care?
Pinto, Daniel
Classifications
Problem Oriented Medical Record
Electronic Health Record
Primary Health Care.
Classificações
Registo Médico Orientado por Problemas
Registo de Saúde Electrónico
Cuidados de Saúde Primários.
title_short What should we code in health records with the International Classification of Primary Care?
title_full What should we code in health records with the International Classification of Primary Care?
title_fullStr What should we code in health records with the International Classification of Primary Care?
title_full_unstemmed What should we code in health records with the International Classification of Primary Care?
title_sort What should we code in health records with the International Classification of Primary Care?
author Pinto, Daniel
author_facet Pinto, Daniel
author_role author
dc.contributor.author.fl_str_mv Pinto, Daniel
dc.subject.por.fl_str_mv Classifications
Problem Oriented Medical Record
Electronic Health Record
Primary Health Care.
Classificações
Registo Médico Orientado por Problemas
Registo de Saúde Electrónico
Cuidados de Saúde Primários.
topic Classifications
Problem Oriented Medical Record
Electronic Health Record
Primary Health Care.
Classificações
Registo Médico Orientado por Problemas
Registo de Saúde Electrónico
Cuidados de Saúde Primários.
description In Portugal, family physicians use the International Classification of Primary Care (ICPC) for coding in their electronic health records. However, questions about the use of the classification in daily practice are common. This text aims to clarify what should be coded in health records. ICPC allows the coding of reasons for encounter, health problems, and the process of care. Users should avoid confusion of these terms with the headings “subjective”, “assessment” and “plan” in follow-up notes of the problem-oriented medical record. In daily practice, most users should limit themselves to the coding of health problems. Family physicians should focus on coding the main problems of the patient and maintaining a list of all problems
publishDate 2014
dc.date.none.fl_str_mv 2014-09-01
dc.type.status.fl_str_mv info:eu-repo/semantics/publishedVersion
dc.type.driver.fl_str_mv info:eu-repo/semantics/article
format article
status_str publishedVersion
dc.identifier.uri.fl_str_mv https://doi.org/10.32385/rpmgf.v30i5.11391
https://doi.org/10.32385/rpmgf.v30i5.11391
url https://doi.org/10.32385/rpmgf.v30i5.11391
dc.language.iso.fl_str_mv por
language por
dc.relation.none.fl_str_mv https://rpmgf.pt/ojs/index.php/rpmgf/article/view/11391
https://rpmgf.pt/ojs/index.php/rpmgf/article/view/11391/11112
dc.rights.driver.fl_str_mv info:eu-repo/semantics/openAccess
eu_rights_str_mv openAccess
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dc.publisher.none.fl_str_mv Associação Portuguesa de Medicina Geral e Familiar
publisher.none.fl_str_mv Associação Portuguesa de Medicina Geral e Familiar
dc.source.none.fl_str_mv Portuguese Journal of Family Medicine and General Practice; Vol. 30 No. 5 (2014): Revista Portuguesa de Medicina Geral e Familiar; 328-34
Revista Portuguesa de Medicina Geral e Familiar; Vol. 30 Núm. 5 (2014): Revista Portuguesa de Medicina Geral e Familiar; 328-34
Revista Portuguesa de Medicina Geral e Familiar; Vol. 30 N.º 5 (2014): Revista Portuguesa de Medicina Geral e Familiar; 328-34
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2182-5173
10.32385/rpmgf.v30i5
reponame:Repositórios Científicos de Acesso Aberto de Portugal (RCAAP)
instname:FCCN, serviços digitais da FCT – Fundação para a Ciência e a Tecnologia
instacron:RCAAP
instname_str FCCN, serviços digitais da FCT – Fundação para a Ciência e a Tecnologia
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reponame_str Repositórios Científicos de Acesso Aberto de Portugal (RCAAP)
collection Repositórios Científicos de Acesso Aberto de Portugal (RCAAP)
repository.name.fl_str_mv Repositórios Científicos de Acesso Aberto de Portugal (RCAAP) - FCCN, serviços digitais da FCT – Fundação para a Ciência e a Tecnologia
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