The pragmatics of coding of the patient's records

• Autor(a) principal: Pinto, Virginia Bentes
• Data de Publicação: 2020
• Outros Autores: Rabelo, Camila Regina de Oliveira, Sales, Odete Mayra Mesquita
• Tipo de documento: Artigo
• Idioma: por
• Título da fonte: Informação & Informação
• Texto Completo: https://ojs.uel.br/revistas/uel/index.php/informacao/article/view/39258
• topic: Coding of patient’s records; Patient’s record; Coding; Indexing; Primary diagnosis; Secondary diagnosis; Codificación de Histórias clinicas del paciente; Histórias clinicas del paciente; Codificación; Indexación; Diagnóstico primário; Diagnóstico secundario; Codificação de prontuários do paciente; Prontuário do paciente; Codificação; Indexação; Diagnóstico primário; Diagnóstico secundário

Introduction: Coding as a translation step in the context of indexing The patient's record is a complex scheme of actions - human or automatic - that seeks to identify the primary and secondary diagnoses and treatments related to people's illness status. For this purpose, the International Statistical Classification of Diseases and Health-Related Problems (CID) is adopted. Objective: reflect about the codification of the patient's records as an indexing exercise in the context of the Archives and Statistics Services, aiming to recover information with better quality. Methodology: Descriptive exploratory research, with a qualitative approach, the corpora being constituted by the discharge summaries of three patient’s records, totaling seven volumes. Thirty-five (35) discharge summaries were analyzed, in order to identify the keywords in the language adopted by the doctors to describe the reason for the patients' hospitalization, the interventions performed and the discharge. Then the mapped words were selected in order to perform the translation to CID-10. Results: thirty (30) words referring to diagnoses, and procedures, being three of them referring to the main diagnosis: M32 - Systemic Lupus Erythematosus (SLE), N18 - Chronic Renal Failure (CRF) and K80.20 - cholelithiasis (COL). For secondary diagnoses, we selected ten: N18 - Chronic Renal Failure; T15 - Secondary hypertension, etc. Four procedures: OBH1 - Orotracheal intubation, OTH00Z1 - Kidney transplantation and OFT44ZZ - Laparoscopic cholecystectomy. Conclusions: It is inferred that coding and indexing are similar both theoretically and pragmatically and that there is a need to codify these documents to recover information with better quality. Finally, the difficulties for such codification result from the nonexistence of a regulation by the Federal Council of Medicine (CFM) that guides all the components that must be included in discharge abstracts so that their wording describes aspects related to the summary of the anamnesis, evolution, procedures and the patient's discharge condition.