7) Ch9: Coding Data from Clinical Documentation

Question 1

Coding

Answer 1

The process of converting observations to alphanumeric representations for data entry; System of standardized symbols and definitions used to categorize/organize info about a group; Allow HCP’s to read about, document, and compare patient or intervention characteristics using common language

• Can be categories of codes and levels of terms w/in each category (poor, fair, normal, etc)
• There isn’t one universally accepted coding system in PT
• Improved through testing and application

Question 2

Disease Codes

Answer 2

Coding for a diagnosis

• ICD-10 codes

Question 3

Disability Codes

Answer 3

ICF coding

• Disadvantage is that there might not be established gradations, categories, or codes defined within each larger component of the model (not ICF)
• ICF, MDS, OASIS, UPDRS, PEDI

Question 4

Operational Definitions

Answer 4

Describe the conceptual idea of code and differences btwn levels w/in a code group; Explain how to use a particular term or measure