Accreditation practice pointer: we use a nationally recognised medical vocabulary for coding

QI1.3 A Our practice team uses a nationally recognised medical vocabulary for coding.

RACGP Standards for general practice

Ideally, general practice clinicians apply a standardised clinical terminology. The benefits are:

• key details of a consultation (eg why a patient attends the practice, the problems managed during a consultation, referrals and requested investigation) are recorded consistently

• data can be retrieved for auditing, quality improvement, and continuity of care

• analysis of general practice data is more accurate and reliable

• less ambiguity, which can happen when free text is used.

Nationally recognised medical vocabularies include the World Health Organization’s (WHO’s) International Classification of Primary Care (ICPC) and SNOMED CT. Australian general practice clinical software systems also recognise DOCLE and PYEFINCH.

Practices that do not use a nationally recognised medical vocabulary, might consider including one in patient health records. This can be achieved by adding standardised vocabulary to the patient management software. General practice could also develop a policy and process to implement a standardised medical vocabulary to encourage consistency of clinical terminology in health records.