4.2 Clinical records and global diagnostic codes.

Abstract

A clinical record should include the personal demographic details of the patient, health status, diagnostic information and management/treatment options. However, clinical records are of little use without effective filing and retrieving systems. Coding is therefore necessary to deal with large amounts of differing data and a global coding system could be effectively developed through the use of information technology. The aim of this section was to review the main existing vocabularies and coding systems and to examine ways of improving their global application. It was concluded that global diagnostic codes would be beneficial to the patient, to the profession and to those responsible for strategic decisions concerning the delivery of health care. Extant dental clinical codes are not accepted widely or applied universally. There is an urgent need to identify existing coding systems and to assess their utility and potential for global application. Every effort should be made to include existing codes in the development of a global coding system on which all specialist areas would need to agree. This would require the provision of an overarching interdisciplinary focus and funding should be made available for this development and its implementation.