Standardized vocabulary and information in health: an encoding is necessary for metabolic syndrome?

• Autor(a) principal: Navarro, Nair
• Data de Publicação: 2013
• Outros Autores: Oliveira, Sergio Pacheco de, Campos, Dayse Pereira, Costa, Felipe Ferreira Ramos
• Tipo de documento: Artigo
• Idioma: por
• Título da fonte: RECIIS (Online)
• Texto Completo: https://www.reciis.icict.fiocruz.br/index.php/reciis/article/view/528
• topic: Vocabulary standards; Metabolic syndrome; International Classification of Diseases – ICD; Health information; Patient medical records; Padrões de vocabulário; Síndrome metabólica; Classificação Internacional de Doenças – CID; Informação em Saúde; Prontuário do paciente

Vocabulary standards define which words should be used to report information. In health care, codes are used to represent diagnoses and procedures, facilitate identification and recording for the purpose of managing individual care and to study public health. In the present study, the need for a specific code for metabolic syndrome (MS) and its inclusion in the International Classification of Diseases is discussed. According to a report by the National Cholesterol Education Program, an individual is considered an MS patient when presenting at least three of the following metabolic abnormalities: high blood pressure, abnormal fasting glucose, dyslipidemia and obesity, which indicate a high risk for cardiovascular disease. Data from the information system and medical records from a primary health center were analyzed to determine the co-occurrence of MS records, known by the code “E90”, and associated morbidities. The results showed that 104 cases were found, but only 25 cases of MS were reported in the medical records. Of these, only 11 were in the center’s information system. The findings suggest that a code should be assigned to MS and disseminated to help managers see its true prevalence.