Diagnostic coding in a plastic surgery unit

Abstract

CODING of clinical information can be used to identify in retrospect patients whose diagnosis, mode of treatment or complications are chosen for review, or it can be the means of recording in detail facts relevant to a prospective trial or a number of simultaneous trials. Information may be coded either by listing patients under diagnostic and therapeutic headings (card index systems), or by recording diagnostic and therapeutic data under individual patient headings, for subsequent correlation by mechanical or electronic means (punch card systems). In general a card index is the more economical way of achieving retrospective identification, while only a punch card system will satisfy the needs of a prospective trial. This paper describes a modified card index system which has been in use in the Plastic Surgery Unit in Bradford for the past 8 years. Many surgeons keep small personal or unit card index files limited to cases of special interest. The Bradford system covers all cases, but within a simple framework of only 26 headings. Detail is retained by recording for each patient a r-line summary of his history, diagnosis and treatment. This summary, with the patient’s name, consultant (by initial), age and hospital number, is typed on to code cards under appropriate diagnostic headings. One quarto-size code card will accommodate records of more than IOO patients. Table I shows the Classification Index; Table II shows typical extracts from 2 code cards. A patient may be coded under I, 2 or 3 headings, in Section A for diagnosis, Section B for treatment, and Section C for complications. The full summary is entered each time. The treatment section is reserved for reconstructive procedures, including all flaps and implants, but excluding for example free skin grafts. The great majority of patients are represented by a single entry only.