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User Guide - Web demo - The University of Sydney

1. ICPC 2 PLus Users Guide Page 105
2. 5 Which code Which classification ccsscssssssssssssssessssssesscsssssssesesesssssssesnsesssessensecssessssessnccssesssessscssccseees 13 SECTION 2 qe 25 INTERNATIONAL CLASSIFICATION FOR PRIMARY CARFE 25 SECTION usus c M 34 THE INTERNATIONAL CLASSIFICATION OF PRIMARY CARE STRUCTURE AND DERIVA W M Ud Doct 34 SECTION 41 cere aaa Uia 38 ABOUT TCPC 2 PLUS cte 38 SECTION ee PP N 46 HINTS FOR USING ICPC 2 PLUS cscssssssssssssessssccesecosssesssssssnesssescesesssesossssenesssenesscsssssosscsscesesenessesoors 46 Getting Started e n 46 Terming with ICPC 2 Pl s rene tre e e i Pe HR e a e FE 46 Analysing Information Stored With Icpc 49 GPS Questions Answered endete tiet aieo recien perti pu u heri edu e sese oet ean 49 SECTION 6 mee 55 THE INTERNATIONAL CLASSIFICATION OF PRIMARY CARE 2 55 APPENDIX 73 lO I DEbc m M 73 APPENDIX B III IILI EE 90 Keyword ADDFeVIQtftI nS
3. the Country Metropolitan Comparison Study and a popular quality assurance option the Morbidity and Therapeutic index All the terms recorded by GPs to describe patient reasons for encounter and the problems managed were classified according to the ICPC However each term was given its own extension code As with Read Clinical Codes multiple key words were attached to each term to facilitate easy access to terms On entry of a key word e g OA a pick list is offered to the user who highlights the term required and clicks or hits return to select it This is called terming rather than coding The clinician should hardly be aware that a code is attached that is the computer s job Used in suitable computerised clinical system ICPC PLUS allows the clinician to save the term as selected it does not replace that term with a higher description of the concept Like Read ICPC PLUS is updated quarterly with additions made in response to users requests USAGE OF THESE CLASSIFICATIONS ICD9 CM A is being used throughout the hospital system in Australia and many other countries Some primary care software relies on selected sub groups of its available codes It is available through the National Coding Centre Read Clinical Codes are being used throughout general practice in the UK and are being trialed in New Zealand in both primary and secondary care About 15 practices in Australia use them most having adopted them a
4. ICPC 2 PLus Users Guide Page 8 Return to Instructions Classification The next question is why classify A classification is merely a method of placing the codes in a sorted and meaningful manner A good structure allows you to manage the data within the practice in terms of groups of codes rather than just a specific individual code We use structured coding systems in many areas of our lives Using an example within a student registration system a typical hierarchical system may be Student ID number is 9435267 94 year of entry 3 faculty of science 5 school of physics 267 7 student number With this structured coding system you can easily identify the number of students who first enrolled in 1994 at the university sort on 94 only the number who first enrolled in the faculty of science in 1994 943 the number specifically studying physics in the faculty in 1994 9435 the individual student Applying the same thinking to general practice where D digestive disease D1 digestive infection D116 specifically gastroenteritis you can select records at all levels all patients who have at least one digestive disease all who have had a digestive infection and all who have suffered specifically from gastroenteritis If the codes are not structured in a hierarchical manner the search at the gastroenteritis level is easy but those above become increasingly difficult Without a hierarchy a search for
5. The objective of ICPC 2 PLUS is to provide a database of medical concepts terms that adequately cover the type and process of care GP s and community health provide in a language that is readily utilised by them ICPC 2 PLUS does not aim to provide a code for every condition identifiable but provides a meaningful structural hierarchy to allow classification grouping and analysis for common similar conditions If you are unable to find a term that adequately defines the medical concept you wish to describe you can record it as a J99 code see Section 7 J codes and requested additional term keys Please fax or send copies of your J99 codes other queries and requested codes to the FMRC for consideration by the ICPC 2 PLUS team We look forward to hearing from you The New Terms list has been removed from THIS electronic version The Full APPENDIX is included in the hardcopy version sent to licensed users ICPC 2 PLus Users Guide Page 99 Appendix D Return to Instructions FMRC Code Groupers by ICPC 2 chapter and component APPENDIX D FMRC CODE GROUPERS FOR ANALYSIS OF MORBIDITY DATA by ICPC 2 chapters and components The Grouper table has been removed from THIS electronic version The Full APPENDIX E is included in the hardcopy version sent to licensed users ICPC 2 PLus Users Guide Page 104 Appendix E Return to Instructions FMRC Code Groupers by ICPC 2 Diagnosis APPENDIX E Version
6. Keywords Term ICPC Code No Speaking Unable to speak N19 002 Speech Unable Inability Talk Keywords that can be used to access a picklist of related terms Medical concept you wish to Automatically allocated when describe you select a term Return to Instructions ICPC 2 PLus Users Guide Page 46 Return to Instructions Term organisation To facilitate the reading of picklists the terms in ICPC 2 PLUS are generally organised using two basic structures 1 Common usage expression eg Irritable bowel syndrome or 2 Problem or Procedure type site organisation eg Pain cardiovascular chest The Problem or Procedure is usually the first word to appear in the term which provides a generic description of the issue to be coded eg pain These first words may be used as keywords when a comprehensive list of all the terms under that generic description is required Problems include words such as lesion inability infection anaemia fracture etc Procedures include words such as excision destruction test admin etc see Section 6 for a list of the standard process components of ICPC components 2 to 6 Type usually includes words such as acute chronic benign malignant etc These are often not designated keywords unless they are particularly relevant to a term The problem or procedure type facilitates terming because it provides a seconda
7. USERS GUIDE ICPC 2 PLUS INSTRUCTIONS This guide consists of six Sections outlining the advantages of coding and classifying your data giving guidelines to the use of ICPC 2 PLus and a number of Appendices which are updated with each release You may print parts of the guide the whole document 77 pages or use it as an on line version on your computer screen This is a demonstration document that has sections removed that are updated and sent to users To navigate through the guide click the blue underlined text to jump to that Section or Appendix The beginning and bottom of most pages has a link to bring you back here Table of Contents Copyright and Licensing Information Section 1 Why code Why classify Which code Which classification Section 2 International Classification for Primary Care Section 3 ICPC Structure and Derivatives Section 4 About ICPC 2 Plus Section 5 Hints for using ICPC 2 Plus Getting Started Terming With ICPC 2 Plus Analysing Information Stored with ICPC 2 Plus GP s Questions Answered Section 6 ICPC 2 Tabular List Appendix A ICPC 2 Plus Keyword List for speedy term access Appendix B ICPC 2 Plus Standardised Keyword Abbreviations for speedy term access Appendix C ICPC 2 Plus New Terms added in this release Appendix D FMRC Code Groups by ICPC 2 chapter and components Appendix E FMRC Code Groups by diagnosis problem concept Family Medicine Research Centre University of Sy
8. problem Alas the experts agree it fails to do so Advantages ICD is an international classification widely used in tertiary institutions in Australia and elsewhere Disadvantages e The rubric i e the ICD description of the medical concept is often a false terminology with little relationship to the natural language of clinicians having been designed for secondary rather than clinician coding e ICD is a static classification It is only revised every 10 15 years so it does not keep up to date with changing medical terminology and the discovery of new diseases lacks sufficient rubrics for the many ill defined conditions managed in primary care Return to Instructions ICPC 2 PLus Users Guide Page 15 Return to Instructions THE READ CLINICAL CODES The Read codes have been described in more detail elsewhere but in summary they are a comprehensive nomenclature of medical terms derived from international classifications such as ICD 9 and OPCS 4 a classification of surgical operations and procedures similar to our CMBS The version presently used in the UK READ 5 byte set includes over 100 000 preferred terms and 150 000 synonyms The original developer a GP named James Read started with a list of terms he used in his practice and asked GPs to try and use it As they requested the addition of other specific terms they were added to RCC It is regularly updated each three months in response to GP need
9. R93 PLEURAL EFFUSION S 11 OTHER LOCALIZED SKIN INFECTION 579 OTHER BENIGN NEOPLASMS OF SKIN 580 OTHER UNSPECIFIED NEOPLASM SKIN S94 INGROWING NAIL OTHER DISEASE OF NAIL T T06 ANOREXIA NERVOSA W WO BULEMIA T15 THYROID LUMP MASS T88 RENAL GLYCOSURIA T89 new rubric in ICPC 2 T90 DIABETES MELLITUS U U08 new rubric in ICPC 2 RISK FACTOR FOR CARDIOVASC DISEASE ISCHAEMIC HEART DISEASE WITH ANGINA ISCHAEMIC HEART DISEASE HEART DISEASE WYO ANGINA CARDIAC ARRYTHMIA NOS HEART ARTERIAL MURMER NOS included with K92 in ICPC 2 Excl Heart Brain CEREBROVASCULAR DISEASE ATHEROSCLEROSIS PERIPH VASC DIS FLANK AXILLA SYMPTOMS COMPLAINTS deleted included in L05 MALIGNANT NEOPLASM NECK SYNDROME BACK SYNDROME WITHOUT RADIATION DISC LESION BACK PAIN WITH RADIATION BURSITIS TENDONITIS SYNOVITIS NOS NEOPLASM BENIGN UNCERTAIN split from L71 in ICPC 2 transferred to N95 ABNORM INVOLUNTARY MOVEMENT split from N06 HEAD INJURY OTHER TENSION HEADACHE transferred from NO2 transferred to P81 SOMATIZATION DISORDER SUICIDE SUICIDE ATTEMPT HYPERKINETIC DISORD transfer from P21 POSTTRAUMATICSTRESS DISORD split from P02 ANOREXIA NERVOSA BULIMIA transferred from T06 deleted included in R21 deleted included in A70 STREP THROAT scarlet fever include A78 CHRONIC BRONCHITIS transfer from R91 INFLUENZA PLEURISY PLEURAL EFFUSION include pleural effusion from transferred to R79 NEOPLASM RE
10. X22 CONCERN ABOUT BREAST APPEARANCE FEMALE X23 FEAR OF SEXUALLY TRANSMITTED DISEASE FEMALE X24 FEAR OF SEXUAL DYSFUNCTION FEMALE X25 FEAR OF CANCER GENITAL FEMALE X26 FEAR OF CANCER OF BREAST FEMALE X27 FEAR OF GENITAL BREAST DISEASE OTHER FEMALE X28 LIMITED FUNCTION DISABILITY GENITAL FEMALE X29 GENITAL SYMPTOM COMPLAINT OTHER FEMALE Return to Instructions ICPC 2 PLus Users Guide Page 70 Return to Instructions Component 2 Component 3 Component 4 Component 5 Component 6 Component 7 Diagnostic Screening amp Preventive Procedures Medication Treatment Procedures Test Results Administrative Referrals amp Other Reason for Encounter Diagnosis diseases X70 SYPHILIS FEMALE X71 GONORRHOEA FEMALE X72 GENITAL CANDIDIASIS FEMALE X73 GENITAL TRICHOMONIASIS FEMALE X74 PELVIC INFLAMMATORY DISEASE X75 MALIGNANT NEOPLASM CERVIX X76 MALIGNANT NEOPLASM BREAST FEMALE X77 MALIGNANT NEOPLASM GENITAL OTHER FEMALE X78 FIBROMYOMA UTERUS X79 BENIGN NEOPLASM BREAST FEMALE X80 BENIGN NEOPLASM GENITAL FEMALE X81 UNCERTAIN NATURE NEOPLASM GENITAL FEMALE X82 INJURY GENITAL FEMALE X83 CONGENITAL ANOMALY GENITAL FEMALE X84 VAGINITIS VULVITIS NOS X85 CERVICAL DISEASE NOS X86 ABNORMAL PAP SMEAR X87 UTEROVAGINAL PROLAPSE X88 FIBROCYSTIC DISEASE BREAST X89 PREMENSTRUAL TENSION SYNDROME X90 GENITAL HERPES FEMALE X91 CONDYLOMATA ACUMINATA FEMALE X92 CHLAMYDIA INFECTION GE
11. patient enters the health care system representing the demand for care by that person They may be symptoms or complaints headache or fear of cancer known diseases flu or diabetes requests for preventive or diagnostic services a blood pressure check or an ECG a request for treatment repeat prescription to get test results or administrative a medical certificate These reasons are usually related to one or more underlying problems which the doctor formulates at the end of the encounter as the conditions that have been treated which may or may not be the same as the reason for the encounter Disease classifications are designed to allow the health care providers interpretation of a patient s health care problem to be coded in the form of an illness disease or injury In contrast a Reason for Encounter classification focuses on data elements from the patient s perspective 9 In this respect it is patient oriented rather than disease or provider oriented The reason for encounter or demand for care given by the patient has to be clarified by the physician or other health worker before there is an attempt to interpret and assess the patient s health problem in terms of a diagnosis or to make any decision about the process of management and care The working group developing the RFE classification tested its several versions in field trials The first field trial to test the completeness and reliability of the RFEC was a pilot
12. 008 HERPANGINA Herpangina 77 008 VIRUS Herpes 77 023 VIRAL Herpes A77 023 HERPES Herpes ATT 023 VIRAL Infection viral ATT 010 INFECTIONS Infection viral A77 010 PSITTACOSI Ornithosis A77 011 ORNITHOSIS Ornithosis A77 011 ORNITHOSIS Psittacosis A77 016 PSITTACOSI Psittacosis A77 016 VIRUS Rabies A77 012 RABIES Rabies A77 012 VIRAL Rabies A77 012 FEVER Ross River fever ATT 013 ROSSRIVER Ross River fever ATT 013 VIRAEMIA Viraemia ATT 017 VIRUS Viraemia ATT 017 BLOOD Viraemia A77 017 VIRAL Viraemia A77 017 VIREMIA Viraemia A77 017 ILLNESS Viral illness A77 005 DISEASE Viral illness A77 005 VIRAL Viral illness A77 005 VIRUS Virus A77 020 FEVER Yellow fever A77 007 VIRAL Yellow fever A77 007 VIRUS Yellow fever A77 007 YELLOW Yellow fever A77 007 Return to Instructions ICPC 2 PLus Users Guide Page 41 Return to Instructions ICPC PLUS The extended medical term index developed from the GP encounter forms was entered in a SQL relational database ICPC PLUS term and code creation Terms codes As each term was entered into the database the computer automatically allocated a term code eg in Fig 4 3 Viral illness term code 005 within ICPC code A77 Thus each term has a unique identifier A77023 which allows storage of the more specific term in the medical record Keywords For each term one or more keywords were allocated eg in Fig 4 3 Term code 005 has three keywords by which access can
13. 8151 Facsimile 02 9845 8155 E mail helenab med usyd edu au LICENSING FEES FOR GENERAL PRACTICE AUSTRALIA AND NEW ZEALAND WONCA SITE LICENSE COSTS once only payment A single licence fee for the lifelong use of ICPC 2 has been set by WONCA at the following rates Single user 100 2 Auser site 150 5 user site 200 The licence fee is payable to the FMRC who pass payment on to WONCA at regular intervals The monies received by WONCA will assist the Classification Committee in continuing its work in further developing classification systems including ICPC 2 for general practice ANNUAL SITE LICENCE FEE FOR ICPC 2 PLUS FOR GENERAL PRACTICE AUSTRALIA AND NEW ZEALAND The annual fees for ICPC 2 PLus have been set by the FMRC at the same rate Single user 120 2 4 user 180 5 10 user 250 11 15 user 310 16 20 user 370 21 user 420 This fee will cover the provision of regular database updates If you feed back terms you find difficult or impossible to find we will add them in time for the next upgrade The University of Sydney is a non profit organisation and any surplus will be utilised for research and development of classification systems for general practice OUTSIDE AUSTRALIA AND NEW ZEALAND BY QUOTATION Return to Instructions ICPC 2 PLus Users Guide Page 3 TABLE OF CONTENTS Return to Instructions SECTIONT1 u 5 Why code Why classify
14. Beaton N Miller G Coding and classification in computerised general practice medical records Why code Why classify Aust Fam Physician 1995 24 612 615 World Health Organisation nternational classification of diseases 9th revision Geneva World Health Organisation 1978 World Health Organisation nternational classification of diseases and related health problems 10th revision Geneva World Health Organisation 1992 Westbury RC Tarrant M Classification of disease in general practice A comparative study Can Med Assoc J 1969 101 82 Miller G Britt H Data collection and changing health care systems 1 United Kingdom Med J Aust 1993 159 471 475 Classification of Surgical Operations and Procedures Version 4 9 London Office of Population Census and Survey Operations 1987 Family Medicine Research Unit University of Sydney The Aus Read Trial Report to the Evaluation Steering Group General Practice Branch Canberra Department of Human Services and Health August 1994 Classification Committee of WONCA CHPPC 2 defined International classification of health problems in primary care Oxford Oxford University Press 1983 Lamberts H and Woods M eds CPC the International classification of primary care Oxford Oxford University Press 1987 Bridges Webb C Britt H Miles DA Neary S Charles J Traynor V Morbidity and treatment in general practice in Australia 1990 1991 Med J Aust 199
15. LEGS N05 TINGLING FINGERS FEET TOES N06 SENSATION DISTURBANCES OTHER N07 CONVULSIONS SEIZURES N08 ABNORMAL INVOLUNTARY MOVEMENTS N16 DISTURBANCE SMELL TASTE N17 VERTIGO DIZZINESS N18 PARALYSIS WEAKNESS N19 SPEECH DISORDER N26 FEAR OF CANCER OF NEUROLOGICAL SYSTEM N27 FEAR OF NEUROLOGICAL DISEASE OTHER N28 LIMITED FUNCTION DISABILITY NEUROLOGICAL N29 NEUROLOGICAL SYMPTOM COMPLAINT OTHER Component 2 Diagnostic Screening amp Preventive Procedures Component 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases N70 POLIOMYELITIS N71 MENINGITIS ENCEPHALITIS N72 TETANUS N73 NEUROLOGICAL INFECTION OTHER N74 MALIGNANT NEOPLASM NERVOUS SYSTEM N75 BENIGN NEOPLASM NERVOUS SYSTEM N76 UNCERTAIN NATURE NEOPLASM NERVOUS SYSTEM N79 CONCUSSION N80 INJURY HEAD OTHER N81 INJURY NERVOUS SYSTEM OTHER N85 CONGENITAL ANOMALY NEUROLOGICAL N86 MULTIPLE SCLEROSIS N87 PARKINSONISM N88 EPILEPSY N89 MIGRAINE N90 CLUSTER HEADACHE N91 FACIAL PARALYSIS BELL S PALSY N92 TRIGEMINAL NEURALGIA N93 CARPAL TUNNEL SYNDROME N94 PERIPHERAL NEURITIS NEUROPATHY N95 TENSION HEADACHE N99 NEUROLOGICAL DISEASE OTHER Return to Instructions Return to Instructions ICPC 2 PLus Users Guide Page 64 P PSYCHOLOGICAL Component 1 Complaints amp Symptoms P01 FEELING ANXIOUS NERVOUS TENSE P02 ACUTE STRESS R
16. MUSCULOSKELETAL SYMPTOM COMPLAINT OTHER Component 2 Diagnostic Screening amp Preventive Procedures Component 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases L70 MUSCULOSKELETAL INFECTION L71 MALIGNANT NEOPLASM MUSCULOSKELETAL L72 FRACTURE RADIUS ULNA L73 FRACTURE TIBIA FIBULA L74 FRACTURE HAND FOOT BONE L75 FRACTURE FEMUR L76 FRACTURE OTHER L77 SPRAINS amp STRAINS OF ANKLE L78 SPRAINS amp STRAINS OF KNEE L79 SPRAINS amp STRAINS OF JOINTS NOS L80 DISLOCATION amp SUBLUXATION L81 INJURY MUSCULOSKELETAL NOS L82 CONGENITAL ANOMALY MUSCULOSKELETAL L83 NECK SYNDROME INCL OSTEOARTHRITIS L84 BACK SYNDROME WITHOUT RADIATING PAIN Return to Instructions ICPC 2 PLus Users Guide Page 63 Return to Instructions L85 ACQUIRED DEFORMITY OF SPINE L86 BACK SYNDROME WITH RADIATING PAIN L87 BURSITIS TENDONITIS SYNOVITIS NOS L88 RHEUMATOID ARTHRITIS L89 OSTEOARTHROSIS OF HIP L90 OSTEOARTHROSIS OF KNEE L91 OSTEOARTHROSIS OTHER L92 SHOULDER SYNDROME INCL ARTHRITIS OSTEOARTHRITIS L93 TENNIS ELBOW L94 OSTEOCHONDROSIS L95 OSTEOPOROSIS L96 ACUTE INTERNAL DAMAGE KNEE L97 BENIGN UNCERTAIN NEOPLASM MUSCULOSKELETAL L98 ACQUIRED DEFORMITY OF LIMB L99 MUSCULOSKELETAL DISEASE OTHER N NEUROLOGICAL Component 1 Complaints amp Symptoms N01 HEADACHE N03 PAIN FACE N04 RESTLESS
17. an increasing number in Australia the concept of terming has been introduced Terming refers to the entry of a few key letters eg osteo an acronym OA or a brief key term to access a list of terms which should include the one you are looking for You select the term from the pick list by a single key stroke ie terming The selected label and its code are automatically entered and stored by the computer In the future as hand written recognition systems are refined and become less expensive you will be able to use the same process with the tip of your pen Coding is regarded by some as only useful in the diagnostic area However increasingly coding systems will include codes for all sorts of information in your medical records including the details of the drugs you prescribe therapeutic procedures pathology results family history risk factors etc This will allow you to undertake more complex record reviews eg to investigate the number of patients who are on risk levels of a selected medication for a selected disease develop reliable recall systems for preventive or follow up care check that none of your patients on NSAIDs also suffer from asthma It is hoped that codes which facilitate the use of warning systems for allergies adverse effects possible contraindications and drug interactions will also soon be available This cannot help but assist general practitioners in the provision of quality care Return to Instructions
18. be the one most often used when you have sufficient information to arrive at a diagnosis in the medical record or problem list It is based on the ICHPPC 2 and most rubrics are directly comparable However the psychological and social chapters of ICPC are drawn from problem lists developed by the WHO sponsored Triaxial Classification Group 6 7 Within this diagnostic component are five sub groups which are not numerically uniform across chapters infectious diseases neoplasms injuries congenital anomalies other diseases Components 1 and 7 in ICPC function independently in each chapter and either can be used to code patient RFEs presenting symptoms or problems managed Components 2 6 are common throughout all chapters each rubric being equally applied to any body system Component 2 covers diagnostic screening prevention It is useful when there is no underlying pathology for the problem under management eg immunisation check up partial or full advice and health instruction Component 3 treatment procedures and medication This component should rarely if ever be used to describe a problem under management as it covers the processes involved in patient care However for those who wish to code procedures as well as problems these codes will prove very useful Components 2 and 3 are based broadly on the ICD 9 Procedures in Medicine 8 and are heavily influenced by the International Classification of Process in Primary C
19. digestive problems would require you to list all the codes which you feel fall into that group Without a code you would have to list and search for all the possible terms you may have used to describe a digestive problem of any type Codes which are classified make any data retrieval easier Return to Instructions ICPC 2 PLus Users Guide Page 9 Return to Instructions One classification system or many There are many levels at which data retrieved from medical records are useful e individual patient information in general practice e information about groups and families in a general practice e community or practice population information e regional health information eg Divisions e State and national information e international comparisons The level of specificity required by each of these participants in the health care system varies considerably Ideally one universal coding system would meet the needs of all these competing interests but this is not usually the case For example a coding system which classifies diseases in terms of broad group headings only eg digestive cardiovascular etc is of little use in the GP surgery when you wish to record code and store minute details about the health event which has occurred to your patient On the other hand the fine detail of a patient record is of little use to a regional health planner who may wish to allocate resources on the basis of broad parameters su
20. the content of general practice the whole process of care needs to be considered including the reasons patients seek care While the concept of recording patients reasons for attendance is relatively new in Australia in many countries increased interest in the patient centred approach to medical care has led GPs to record the patients RFE in their medical records as a matter of course In Australian general practice it is more likely that the GP will record presenting symptoms which may represent only part of the patient s RFE ICPC is ideal for recording both RFEs and presenting symptoms and it is up to the individual general practitioner to decide whether either or both of these elements are to be coded SOAP Therefore three of the four parts of a patient s problem oriented clinical record which reflect the essential elements of each patient provider encounter can be coded using the ICPC Return to Instructions ICPC 2 PLus Users Guide Page 34 Return to Instructions S Subjective the patient s reason for encounter or presenting symptoms Objective this element cannot be classified using ICPC A Assessment the provider s interpretation of the problem in the form of a diagnosis or problem label P Plan the process of care intervention undertaken by the provider ICPC STRUCTURE It has a biaxial structure with 17 chapters on one axis and seven components on the other Chapters are based on body systems with a
21. the selection of records for groups of patients coding aids the linkage of events over time within a patient record Using a single code to represent the disease or problem during a consultation you can ask the computer to show you all encounters for this patient at which code X was managed and view them consecutively on the screen This is far easier than searching through pages and pages of records whether on paper or computer when trying to build a historical view of the progress of a disease or of its management Return to Instructions ICPC 2 PLus Users Guide Page 7 Return to Instructions Coding may also have some disadvantages which include the impact it has on the style of practice of the doctor It requires the practitioner to think more specifically about the term selected to describe a problem Coding systems must therefore be sufficiently flexible to allow individual preferences in terminology whilst maintaining accurate interpretation by others Like computerised records the introduction of coding systems requires a new form of discipline and a new way of thinking about records by professionals Some people suggest that coding the problems and their management is an extra job for the clinician They inevitably describe the time consuming task of looking up a list selecting the code and then entering it on the record manually Think again Things are fast changing In most software systems available overseas and in
22. to allow access to information from multiple sources using different medical terminology It is however being used experimentally in several hospitals in the United States for the coding of medical problems In addition to these international systems there are a multitude of Australian home grown coding systems which do not have an international basis The most well known of these is Docle which is based on the Linnean model invented some 200 years ago for the classification of species Unlike other systems it does not utilise numeric codes It was described at a recent conference as made up of two core concepts The first core concept of Docle is an algorithm that converts a piece of real world medical vernacular into a standard abbreviation For example diabetes mellitus is repackaged by the Docle algorithm as diabetesMellitus before it maps to the Docle word diabm The second core concept is that of operators Docle words can be combined together to form any number of complicated expressions by combining Docle terms with operators For example a fracture of the radius can be expressed as frac radi the dot operator translates to located at Docle is being used by one Australian GP software vendor Return to Instructions ICPC 2 PLus Users Guide Page 22 Return to Instructions CONCLUSION When selecting a coding system you need to consider the issues raised above All classifications have some disadvantages
23. 04 01 FMRC REPORT CODE GROUPERS USING ICPC 2 by diagnosis When searching for patients who have a particular condition either for self audit or for patient recall the problem diagnosis for which you are searching may not always be contained within a single ICPC 2 PLUS term or even an ICPC 2 rubric To assist in these reports searches of your records the Family Medicine Research Centre has undertaken significant work to improve the quality of groupers available in ICPC 2 PLUS This work has resulted in a more comprehensive list of concept types both within and across rubrics and chapters HINTS when utilising ICPC 2 PLUS s inbuilt groupers If you are searching for a set of patients who may fulfill multiple criteria of a grouper e g your search all patients with High BP OR Simple Hypertension OR Hypertension with complications If your patient was originally labeled high BP and later diagnosed as hypertension your software could identify this patient more than once What is the solution You need to ensure that your search can run a count of patients who fulfill at least one of the criteria codes listed for your grouper Check with your software supplier to ensure this is feasible If this sounds confusing check the hypertension grouper criteria listed on page E 8 The Grouper list has been removed from THIS electronic version The Full APPENDIX E IS included in the hardcopy version sent to licensed users
24. 2 157 Suppl 51 556 Britt H Miles DA Bridges Webb C Neary S Charles J Traynor V A comparison of country and metropolitan general practice Med J Aust 1993 159 Suppl S9 S64 Oon YK The Linnean Model of Medical Classification In the Proceeedings of the Fourth National Health Informatics Conference pp153 9 Melbourne Health Informatics Society of Australia August 1996 Return to Instructions ICPC 2 PLus Users Guide Page 24 SECTION 2 Return to Instructions INTERNATIONAL CLASSIFICATION FOR PRIMARY CARE Charles Bridges Webb Emeritus Professor of General Practice University of Sydney and Chairman WONCA Classification Committee Introduction The International Classication of Disease ICD is the most widely recognised classification of diseases The advent of yet another revision the tenth ICD 10 in 1992 can cause confusion for those familiar with the currently used ICD 9 This may be even worse for primary health care physicians who may also need to use other classifications such as the International Classification of Health Problems in Primary Care or the International Classification of Primary Care ICPC ICPC 2 The difficulties might be lessened by an account of their historical development role relationships and relative merits Classification nomenclature and thesaurus Firstly however it is important to appreciate what a classification is and how it differs
25. 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases T70 ENDOCRINE INFECTION T71 MALIGNANT NEOPLASM THYROID T72 BENIGN NEOPLASM THYROID T73 NEOPLASM ENDOCRINE OTHER UNSPECIFIED T78 THYROGLOSSAL DUCT CYST T80 CONGENITAL ANOMALY ENDOCRINE METABOLIC T81 GOITRE T82 OBESITY BMI gt 30 T83 OVERWEIGHT BMI lt 30 T85 HYPERTHYROIDISM THYROTOXICOSIS T86 HYPOTHYROIDISM MYXOEDEMA T87 HYPOGLYCEMIA T88 deleted transferred to t99 T89 DIABETES INSULIN DEPENDENT T90 DIABETES NON INSULIN DEPENDENT T91 VITAMIN NUTRITIONAL DEFICIENCY T92 GOUT T93 LIPID DISORDER T99 ENDOCRINE METABOLIC NUTRITIONAL DISEASE OTHER Return to Instructions ICPC 2 PLus Users Guide Page 68 Return to Instructions U UROLOGICAL Component 1 Complaints amp Symptoms 001 DYSURIA PAINFUL URINATION 002 URINARY FREQUENCY URGENCY U04 INCONTINENCE URINE 005 URINATION PROBLEMS OTHER U06 HAEMATURIA U07 URINE COMPLAINTS OTHER U08 URINARY RETENTION U13 BLADDER SYMPTOM COMPLAINT OTHER U14 KIDNEY SYMPTOM COMPLAINT U26 FEAR OF CANCER OF URINARY SYSTEM U27 FEAR OF URINARY DISEASE OTHER U28 LIMITED FUNCTION DISABILITY URINARY U29 URINARY SYMPTOM COMPLAINT OTHER Component 2 Diagnostic Screening amp Preventive Procedures Component 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases U70 P
26. CABIES AND OTHER ACARIASES S73 PEDICULOSIS SKIN INFESTATIONS OTHER S74 DERMATOPHYTOSIS 575 MONILIASIS CANDIDIASIS SKIN S76 SKIN INFECTION OTHER 577 MALIGNANT NEOPLASM SKIN 578 LIPOMA S79 BENIGN UNCERTAIN NEOPLASM SKIN S80 SOLAR KERATOSIS SUNBURN S81 HAEMANGIOMA LYMPHANGIOMA S82 NAEVUS MOLE S83 CONGENITAL ANOMALY SKIN OTHER S84 IMPETIGO S85 PILONIDAL CYST FISTULA S86 DERMATITIS SEBORRHOEIC S87 DERMATITIS ATOPIC ECZEMA S88 DERMATITIS CONTACT ALLERGIC S89 DIAPER RASH S90 PITYRIASIS ROSEA S91 PSORIASIS S92 SWEAT GLAND DISEASE S93 SEBACEOUS CYST S94 INGROWNING NAIL S95 MOLLUSCA CONTAGIOSUM S96 ACNE S97 CHRONIC ULCER SKIN INCL VARICOSE ULCER S98 URTICARIA S99 SKIN DISEASE OTHER Return to Instructions T ENDOCRINE METABOLIC AND NUTRITIONAL ICPC 2 PLus Users Guide Page 67 Component 1 Complaints amp Symptoms T01 EXCESSIVE THIRST T02 EXCESSIVE APPETITE LOSS OF T04 FEEDING PROBLEM OF INFANT CHILD 1705 FEEDING PROBLEM OF ADULT 07 WEIGHT GAIN 08 WEIGHT LOSS T10 GROWTH DELAY T11 DEHYDRATION T26 FEAR OF CANCER OF ENDOCRINE SYSTEM T27 FEAR OF ENDOCRINE METABOLIC DISEASE OTHER T28 LIMITED FUNCTION DISABILITY ENDOCRINE METABOLIC T29 ENDOCRINE METAB NUTRITION SYMPTOM COMPLAINT OTHER Component 2 Diagnostic Screening amp Preventive Procedures Component 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component
27. EACTION P03 FEELING DEPRESSED P04 FEELING BEHAVING IRRITABLE ANGRY P05 SENILITY FEELING BEHAVING OLD P06 SLEEP DISTURBANCE P07 SEXUAL DESIRE REDUCED P08 SEXUAL FULFILMENT REDUCED P09 CONCERN ABOUT SEXUAL PREFERENCE P10 STAMMERING STUTTERING TICS P11 EATING PROBLEMS IN CHILDREN P12 BEDWETTING ENURESIS P13 ENCOPRESIS BOWEL TRAINING PROBLEM P15 CHRONIC ALCOHOL ABUSE P16 ACUTE ALCOHOL ABUSE P17 TOBACCO ABUSE P18 MEDICATION ABUSE P19 DRUG ABUSE P20 MEMORY DISTURBANCE P22 CHILD BEHAVIOR SYMPTOM COMPLAINT P23 ADOLESCENT BEHAVIOUR SYMPTOM COMPLAINT P24 SPECIFIC LEARNING PROBLEM P25 PHASE OF LIFE PROBLEM IN ADULT P27 FEAR OF MENTAL DISORDER P28 LIMITED FUNCTION DISABILITY PSYCHOLOGICAL P29 PSYCHOLOGICAL SYMPTOM COMPLAINT OTHER Component 2 Diagnostic Screening amp Preventive Procedures Component 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases P70 DEMENTIA INCL SENILE ALZHEIMER P71 ORGANIC PSYCHOSIS OTHER P72 SCHIZOPHRENIA P73 AFFECTIVE PSYCHOSIS P74 ANXIETY DISORDER ANXIETY STATE P75 SOMATISATION DISORDER P76 DEPRESSIVE DISORDER P77 SUICIDE SUICIDE ATTEMPT P78 NEURASTHENIA SURMENAGE P79 PHOBIA COMPULSIVE DISORDER P80 PERSONALITY DISORDER P81 HYPERKINETIC DISORDER P82 POST TRAUMATIC STRESS DISORDER P85 MENTAL RETARDATION P86 ANOREXIA NERVOSA BULIMIA P98 PSYCHOSES NOS O
28. ESCENDED TESTICLE Y84 CONGENITAL ANOMALY GENITAL MALE Y85 BENIGN PROSTATIC HYPERTROPHY Y86 HYDROCOELE Y99 GENITAL DISEASE OTHER MALE INCL BREAST 2 SOCIAL PROBLEMS Component 1 Complaints amp Symptoms 201 POVERTY FINANCIAL PROBLEM 202 FOOD AND WATER PROBLEM 203 HOUSING NEIGHBORHOOD PROBLEM Z04 SOCIAL CULTURAL PROBLEM 205 WORK PROBLEM Z06 UNEMPLOYMENT PROBLEM 207 EDUCATION PROBLEM 208 SOCIAL WELFARE PROBLEM 209 LEGAL PROBLEM Z10 HEALTH CARE SYSTEM PROBLEM Z11 COMPLIANCE BEING ILL PROBLEM 212 RELATIONSHIP PROBLEM PARTNERS Z13 PARTNER BEHAVIOUR PROBLEM 214 PARTNER ILLNESS PROBLEM Z15 LOSS OR DEATH OF PARTNER INCL MARITAL BREAKDOWN Z16 RELATIONSHIP PROBLEM CHILD Z18 ILLNESS PROBLEM WITH CHILD Z19 LOSS OR DEATH OF CHILD Z20 RELATIONSHIP PROBLEM PARENT FAMILY 221 BEHAVIOR PROBLEM PARENT FAMILY 222 ILLNESS PROBLEM PARENT FAMILY Z23 LOSS DEATH OF PARENT FAMILY MEMBER 224 RELATIONSHIP PROBLEM FRIENDS 225 ASSAULT HARMFUL EVENT 227 FEAR OF SOCIAL PROBLEM 228 SOCIAL HANDICAP 229 SOCIAL PROBLEM NOS Return to Instructions ICPC 2 PLus Users Guide Page 72 Appendix A Return to Instructions Keyword List APPENDIX A Version 4 01 ICPC 2 PLUS KEYWORDS A comprehensive list of ICPC 2 PLUS keywords has been provided to enable users to acquire a firm understanding of keywords available and to assist in the selection of the most appropriate access route to a term 1 You will note
29. FEs and problems managed in the Australian Morbidity and Treatment Survey and in a popular Quality Assurance option the Morbidity and Therapeutic Index MTI The FMRU have secondarily coded over 3 4 of a million patient RFEs and equivalent numbers of problems managed from paper based encounter records completed by general practitioners throughout Australia In the early stages of this paper based coding it was evident that high inter and intra coder reliability was difficult to attain with ICPC Errors in the index were noted and the classification s layout was sometimes confusing But more importantly the ICPC s alphabetical index was found to be inadequate for reliable coding of many terms commonly recorded by GPs From 1991 97 thousands of terms were added by the FMRU to the ICPC index to facilitate access to the correct code When unsure of where to place a term in ICPC the Chairman of the WONCA Classification Committee was referred to who by reference to ICD 9 10 selected the correct code Utilising this mechanism the index continued its expansion on the basis of terminology used by Australian GPs to describe patient RFEs and diagnoses Return to Instructions ICPC 2 PLus Users Guide Page 38 Return to Instructions Development of the computerised database The FMRU found that using ICPC with a widely expanded index worked well in a centralised paper based coding system and provided sufficient specificity for ep
30. ICPC 2 This should not be entered as a new problem in your problem list Rather your software should allow a change of label for the old problem of headache Your software will include an audit trail for legal purposes which should include the old diagnosis and the date of change to the new Return to Instructions ICPC 2 PLus Users Guide Page 52 Return to Instructions The aim of a problem list in a medical record or summary is to ensure that each problem is only recorded once This means that each time you go to enter any information you should view your problem list to check whether the problem is already on the list Otherwise double recording of the same problem with different labels can occur For example A patient arrives for Pap smear You do a breast check as well and select check up partial genital F X31 003 from your pick list The patient s Pap smear was insufficient and re test is required You request the patient s re attendance and on this occasion only do the Pap smear You may be tempted to enter this problem as Pap smear which will be allocated ICPC 2 PLUS code X37 001 If you look at your problem list you now have two problems both of which cover the same medical concept one just being slightly more specific than the other In fact the follow up visit for the Pap smear should have been entered under the old problem of female genital check When the results return they show an abnormality You could
31. INFECTION SEPSIS W71 INFECTIONS COMPLICATING PREGNANCY W72 MALIGNANT NEOPLASM RELATED TO PREGNANCY W73 BENIGN UNCERTAIN NEOPLASM RELATED TO PREGNANCY W75 INJURY COMPLICATING PREGNANCY W76 CONGENITAL ANOMALY COMPLICATING PREGNANCY W78 PREGNANCY W79 UNWANTED PREGNANCY W80 ECTOPIC PREGNANCY W81 TOXAEMIA OF PREGNANCY W82 ABORTION SPONTANEOUS W83 ABORTION INDUCED W84 PREGNANCY HIGH RISK w85 GESTATIONAL DIABETES W90 UNCOMPLICATED DELIVERY LIVEBIRTH W91 UNCOMPLICATED DELIVERY STILLBIRTH W92 COMPLICATED DELIVERY LIVEBIRTH W93 COMPLICATED DELIVERY STILLBIRTH W94 PUERPERAL MASTITIS W95 BREAST DISORDER IN PREGNANCY PUERPERIUM OTHER W96 COMPLICATIONS OF PUERPERIUM OTHER W99 DISORDERS OF PREGNANCY DELIVERY OTHER X FEMALE GENITAL Component 1 Complaints amp Symptoms X01 PAIN GENITAL FEMALE X02 PAIN MENSTRUAL X03 PAIN INTERMENSTRUAL X04 PAINFUL INTERCOURSE FEMALE X05 MENSTRUATION ABSENT SCANTY X06 MENSTRUATION EXCESSIVE X07 MENSTRUATION IRREGULAR FREQUENT X08 INTERMENSTRUAL BLEEDING X09 PREMENSTRUAL SYMPTOM COMPLAINT X10 POSTPONEMENT OF MENSTRUATION X11 MENOPAUSAL SYMPTOM COMPLAINT X12 POSTMENOPAUSAL BLEEDING X13 POSTCOITAL BLEEDING X14 VAGINAL DISCHARGE X15 VAGINAL SYMPTOM COMPLAINT OTHER X16 VULVAL SYMPTOM COMPLAINT X17 PELVIS SYMPTOM COMPLAINT FEMALE X18 PAIN BREAST FEMALE X19 BREAST LUMP MASS FEMALE X20 NIPPLE SYMPTOM COMPLAINT FEMALE X21 BREAST SYMPTOM COMPLAINT OTHER FEMALE
32. IS MEDIA H73 EUSTACHIAN SALPINGITIS H74 CHRONIC OTITIS MEDIA H75 NEOPLASM EAR H76 FOREIGN BODY IN EAR H77 PERFORATION EAR DRUM H78 INJURY EAR SUPERFICIAL H79 INJURY EAR OTHER H80 CONGENITAL ANOMALY EAR H81 EXCESSIVE EAR WAX H82 VERTIGINOUS SYNDROMES H83 OTOSCLEROSIS H84 PRESBYACUSIS H85 ACOUSTIC TRAUMA H86 DEAFNESS H99 EAR MASTOID DISEASE OTHER K CARDIOVASCULAR Component 1 Complaints amp Symptoms K01 PAIN HEART K02 PRESSURE TIGHTNESS OF HEART PAIN CARDIOVASCULAR NOS K04 PALPITATIONS AWARENESS OF HEART K05 IRREGULAR HEARTBEAT OTHER PROMINENT VEINS K07 SWOLLEN ANKLES OEDEMA K22 RISK FACTOR FOR CARDIOVASCULAR DISEASE K24 FEAR OF HEART DISEASE K25 FEAR OF HYPERTENSION K27 FEAR OF CARDIOVASCULAR DISEASE OTHER K28 LIMITED FUNCTION DISABILITY CARDIOVASCULAR K29 CARDIOVASCULAR SYMPTOM COMPLAINT OTHER Component 2 Component 3 Component 4 Component 5 Component 6 Component 7 Diagnostic Screening amp Preventive Procedures Medication Treatment Procedures Test Results Administrative Referrals amp Other Reason for Encounter Diagnosis diseases K70 CARDIOVASCULAR SYSTEM INFECTION K71 RHEUMATIC FEVER HEART DISEASE K72 NEOPLASM CARDIOVASCULAR K73 CONGENITAL ANOMALY CARDIOVASCULAR K74 ISCHAEMIC HEART DISEASE WITH ANGINA K75 ACUTE MYOCARDIAL INFARCTION K76 ISCHAEMIC HEART DISEASE WITHOUT ANGINA K77 HEART FAILURE K78 ATRIAL FIBRILLATION FLUTTER K79 PAROXYSMAL TACHYCARDIA
33. K80 CARDIAC ARRHYTHMIA NOS K81 HEART ARTERIAL MURMER NOS K82 PULMONARY HEART DISEASE K83 HEART VALVE DISEASE NOS Return to Instructions Return to Instructions K84 HEART DISEASE OTHER K85 ELEVATED BLOOD PRESSURE K86 HYPERTENSION UNCOMPLICATED K87 HYPERTENSION COMPLICATED ICPC 2 PLus Users Guide Page 62 K88 POSTURAL HYPOTENSION LOW BLOOD PRESSURE K89 TRANSIENT CEREBRAL ISCHAEMIA K90 STROKE CEREBROVASCULAR ACCIDENT K91 CEREBROVASCULAR DISEASE EXCL HEART BRAIN K92 ATHEROSCLEROSIS PERIPHERAL VASCULAR DISEASE K93 PULMONARY EMBOLISM K94 PHLEBITIS AND THROMBOPHLEBITIS K95 VARICOSE VEINS OF LEG K96 HAEMORRHOIDS K99 CARDIOVASCULAR DISEASE OTHER L MUSCULOSKELETAL Component 1 Complaints amp Symptoms 101 NECK SYMPTOM COMPLAINT L02 BACK SYMPTOM COMPLAINT L03 LOW BACK SYMPTOM COMPLAINT 104 CHEST SYMPTOM COMPLAINT L05 FLANK AXILLA SYMPTOM COMPLAINT 107 JAW SYMPTOM COMPLAINT L08 SHOULDER SYMPTOM COMPLAINT L09 ARM SYMPTOM COMPLAINT L10 ELBOW SYMPTOM COMPLAINT L11 WRIST SYMPTOM COMPLAINT L12 HAND amp FINGER SYMPTOM COMPLAINT L13 HIP SYMPTOM COMPLAINT L14 LEG THIGH SYMPTOM COMPLAINT L15 KNEE SYMPTOM COMPLAINT L16 ANKLE SYMPTOM COMPLAINT L17 FOOT amp TOE SYMPTOM COMPLAINT L18 PAIN MUSCLE L19 MUSCLE SYMPTOM COMPLAINT NOS L20 JOINT SYMPTOM COMPLAINT NOS L26 FEAR OF CANCER MUSCULOSKELETAL L27 FEAR OF MUSCULOSKELETAL DISEASE OTHER L28 LIMITED FUNCTION DISABILITY MUSCULOSKELETAL L29
34. KUP SIDE EFFECT replaced with SIDEEFFECT X RAY replaced with XRAY No space HIGH BLOOD replaced with HIGHBLOOD POST TERM replaced with POSTTERM CIN 1replaced with CIN1 PORT WINE replaced with PORTWINE Use singular keywords instead of plural Eg TOEinstead of TOES INJURY instead of INJURIES TEST instead of TESTS NB You will see that the keyword listing provided in Appendix A uses pleural rather than singular syntax In general the keywords on the list are the longest version of the most suitable keyword The list has been created this way as a precaution for users who might forget to use singular keywords It is advised however that users adopt generally a practice of entering keywords in their singular form Keyword selection If you cannot find the term you require consider spelling ICPC 2 PLUS generally uses Australian English rather than American eg Oesophagus NOT esophagus immunisation NOT immunization entering a shorter version of the keyword eg Arteri instead of arteriosus thrombo instead of thrombocytic The shorter the keyword the wider the picklist a different form of the word e g aged or aging allergic or allergy absent or absence depression or depressive or depressed the term organisation ie Common usage or problem type site structure Return to Instructions ICPC 2 PLus Users Guide Page 48 Return to Instructions Analysing Information Stored With ICPC 2 P
35. LUS Code groupers When trying to analyse the data you have recorded the medical concept of interest may not always be contained within a single term The example of hypertension was described earlier Another example is the concept of depression there are two codes available one for the diagnosis of depression and one for the symptom of feeling depressed If searching for all patients with any form of depression you may wish to search the database for the occurrence of BOTH codes P03 and P76 A list of code groupers is provided below in Figure 5 1 and should be available in your software Major chapter component groups These have been discussed earlier The corrected chapter component groups are presented below Figure 5 2 and have been provided to your software supplier for incorporation into your software GPs Questions Answered The FMRC has received several inquiries from users of ICPC 2 PLUS which suggest that some hints about its application in a clinical setting may be helpful Question Can appendicectomy mastectomy and hysterectomy be coded Answer YES These are all terms which refer to a process rather than to a diagnosis or problem under management ICPC 2 PLUS now covers these procedural terms if you wish to record problems in this form in the History section of a record This brings up the issue of how the meaning of a medical term may change according to where it is in the medical record If you record appe
36. LYTIC ANAEMIAS B79 CONGENITAL ANOMALY BLOOD LYMPH OTHER B80 IRON DEFICIENCY ANAEMIA B81 ANAEMIA VITAMIN B12 FOLATE DEFICIENCY B82 ANAEMIA OTHER UNSPECIFIED B83 PURPURA COAGULATION DEFECTS B84 ABNORMAL WHITE CELLS B87 SPLENOMEGALY B90 HIV INFECTION AIDS B99 BLOOD LYMPH SPLEEN DISEASE OTHER Return to Instructions ICPC 2 PLus Users Guide Page 59 Return to Instructions D DIGESTIVE Component 1 Complaints amp Symptoms D01 PAIN CRAMPS ABDOMINAL GENERAL D02 PAIN ABDOMINAL EPIGASTRIC D03 HEARTBURN D04 PAIN RECTAL ANAL D05 PERIANAL ITCHING D06 PAIN ABDOMINAL LOCALIZED OTHER D07 DYSPEPSIA INDIGESTION D08 FLATULENCE GAS BELCHING D09 NAUSEA D10 VOMITING D11 DIARRHOEA D12 CONSTIPATION D13 JAUNDICE D14 HAEMATEMESIS VOMITING BLOOD D15 MELAENA D16 RECTAL BLEEDING D17 INCONTINENCE OF BOWEL D18 CHANGE IN FAECES BOWEL MOVEMENTS D19 TEETH GUM SYMPTOM COMPLAINT D20 MOUTH TONGUE LIP SYMPTOM COMPLAINT D21 SWALLOWING PROBLEMS D23 HEPATOMEGALY D24 ABDOMINAL MASS NOS D25 ABDOMINAL DISTENSION D26 FEAR OF CANCER OF DIGESTIVE SYSTEM D27 FEAR OF DIGESTIVE DISEASE OTHER D28 LIMITED FUNCTION DISABILITY DIGESTIVE D29 DIGESTIVE SYMPTOM COMPLAINT OTHER Component 2 Diagnostic Screening amp Preventive Procedures Component 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases D70 GA
37. NCHUS R88 INJURY RESPIRATORY OTHER R89 CONGENITAL ANOMALY RESPIRATORY R90 HYPERTROPHY TONSILS ADENOIDS R92 UNCERTAIN NATURE NEOPLASM RESPIRATORY R95 CHRONIC OBSTRUCTIVE PULMONARY DISEASE R96 ASTHMA R97 ALLERGIC RHINITIS R98 HYPERVENTILATION SYNDROME R99 RESPIRATORY DISEASE OTHER Return to Instructions ICPC 2 PLus Users Guide Page 66 Return to Instructions S SKIN Component 1 Complaints amp Symptoms S01 PAIN TENDERNESS OF SKIN S02 PRURITUS S03 WARTS S04 LUMP SWELLING LOCALISED S05 LUMP SWELLING MULTIPLE S06 RASH LOCALIZED S07 RASH GENERALIZED S08 SKIN COLOR CHANGE S09 INFECTED FINGER TOE S10 BOIL CARBUNCLE 511 SKIN INFECTION POST TRAUMATIC 12 INSECT BITE STING 13 ANIMAL HUMAN BITE 14 BURNS SCALDS 15 FOREIGN BODY IN SKIN 516 BRUISE CONTUSION S17 ABRASION SCRATCH BLISTER 18 LACERATION CUT 19 INJURY SKIN OTHER 20 CORNS CALOSITIES 21 SKIN TEXTURE SYMPTOM COMPLAINT 22 NAIL SYMPTOM COMPLAINT 23 HAIR LOSS BALDNESS INCL ALOPECIA 524 HAIR SCALP SYMPTOM COMPLAINT 526 FEAR OF CANCER OF SKIN S27 FEAR OF SKIN DISEASE OTHER 528 LIMITED FUNCTION DISABILITY SKIN 529 SKIN SYMPTOM COMPLAINT Component 2 Diagnostic Screening amp Preventive Procedures Component 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases S70 HERPES ZOSTER S71 HERPES SIMPLEX S72 S
38. NITAL FEMALE X99 GENITAL DISEASE OTHER FEMALE Y MALE GENITAL Component 1 Complaints amp Symptoms Y01 PAIN PENIS Y02 PAIN TESTIS SCROTUM Y03 URETHRAL DISCHARGE MALE Y04 PENIS SYMPTOM COMPLAINT Y05 SCROTUM TESTIS SYMPTOM COMPLAINT Y06 PROSTATE SYMPTOM COMPLAINT Y07 IMPOTENCE NOS Y08 SEXUAL FUNCTION SYMPTOM COMPLAINT MALE Y10 INFERTILITY SUBFERTILITY MALE Y13 STERILISATION MALE Y14 FAMILY PLANNING OTHER MALE Y16 BREAST SYMPTOM COMPLAINT MALE Y24 FEAR OF SEXUAL DYSFUNCTION Y25 FEAR OF SEXUALLY TRANSMITTED DISEASE MALE Y26 FEAR OF CANCER GENITAL MALE Y27 Y28 Y29 FEAR OF GENITAL DISEASE OTHER MALE LIMITED FUNCTION DISABILITY GENITAL MALE GENITAL SYMPTOM COMPLAINT OTHER MALE Component 2 Component 3 Component 4 Component 5 Component 6 Component 7 Diagnostic Screening amp Preventive Procedures Medication Treatment Procedures Test Results Administrative Referrals amp Other Reason for Encounter Diagnosis diseases Y70 SYPHILIS MALE Y71 GONORRHOEA MALE Y72 GENITAL HERPES MALE Y73 PROSTATITIS SEMINAL VESICULITIS Y74 ORCHITIS EPIDIDYMITIS Return to Instructions Y75 BALANITIS Y76 CONDYLOMATA ACUMINATA MALE Y77 MALIGNANT NEOPLASM PROSTATE ICPC 2 PLus Users Guide Page 71 Y78 MALIGNANT NEOPLASM GENITAL OTHER MALE Y79 BENIGN UNCERTAIN NEOPLASM GENITAL MALE Y80 INJURY GENITAL MALE Y81 PHIMOSIS REDUNDANT PREPUCE Y82 HYPOSPADIA Y83 UND
39. POISONING BY MEDICAL AGENT A85 ADVERSE EFFECT MEDICAL AGENT A86 TOXIC EFFECT NON MEDICAL SUBSTANCE A87 COMPLICATION OF TREATMENT A88 ADVERSE EFFECTS PHYSICAL FACTORS A89 EFFECTS PROSTHETIC DEVICE A90 CONGENITAL ANOMALY NOS MULTIPLE A91 ABNORMAL RESULTS INVESTIGATION NOS A92 ALLERGY ALLERGIC REACTION NOS A93 PREMATURE NEWBORN A94 PERINATAL MORBIDITY OTHER A95 PERINATAL MORTALITY A96 DEATH A97 NO DISEASE A98 HEALTH MAINTENANCE PREVENTIVE MEDICINE A99 GENERAL DISEASE NOS NOTE Livebirth Infant under 37 weeks NOTE Death originating in utero or within 7 days of birth B BLOOD BLOOD FORMING ORGANS AND IMMUNE MECHANISM Component 1 Complaints amp Symptoms B02 PAINFUL ENLARGED LYMPH GLAND S B04 BLOOD SYMPTOM COMPLAINT B25 FEAR OF AIDS B26 FEAR OF CANCER BLOOD LYMPH B27 FEAR OF BLOOD LYMPH DISEASE OTHER B28 LIMITED FUNCTION DISABILITY BLOOD LYMPH B29 BLOOD AND IMMUNE MECHANISM SYMPTOM COMPLAINT Component 2 Diagnostic Screening amp Preventive Procedures Component 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases B70 LYMPHADENITIS ACUTE B71 LYMPHADENITIS NON SPECIFIC B72 HODGKIN S DISEASE LYMPHOMAS B73 LEUKAEMIA B74 MALIGNANT NEOPLASM BLOOD OTHER B75 BENIGN UNCERTAIN NEOPLASM BLOOD LYMPH B76 RUPTURED SPLEEN TRAUMATC B77 INJURY BLOOD LYMPH SPLEEN OTHER B78 HEREDITARY HAEMO
40. S PUBLISHED IN INFORMATICS IN HEALTH CARE AUSTRALIA September October 1996 Vol 5 No 4 Return to Instructions Which code Which classification Helena Britt In the past few years there has been considerable discussion about whether or not coding data in computerised clinical systems is necessary or even desirable 2 More recently in parallel with wider adoption of computerised clinical systems in primary care such discussion has subsided suggesting a broader acceptance of the need to code and classify However as it appears that the Commonwealth Government is unlikely to make a directive decision about a set of preferred classifications for primary care in the foreseeable future it is probably time to review the advantages and disadvantages of those that are available While this paper concentrates on morbidity classifications we should not lose sight of the need to code other fields in the patient s record In the recently completed NSW data modeling exercise for Community Health over 400 data items which could be classified were identified These included some fields that clinicians automatically classify For example e the type of consultation in general practice this is classified with the Commonwealth Medical Benefits Schedule CMBS e patient characteristics such as age and sex are automatically classified through habit Many other patient characteristics such as country of birth language spoken at home etc c
41. SPIRAT UNCERT NATURE deleted included in R82 WOUND INFECTION POST TRAUMATIC NEOPLASM SKIN BENIGN UNCERTAIN SOLAR KERATOSIS SUNBURN INGROWING NAIL oth disease of nail S99 transferred to P86 deleted included in T81 deleted included in T99 DIABETES INSULIN DEPENDENT DIABETES NON INSULIN DEPENDENT URINARY RETENTION ICPC 2 PLus Users Guide Page 56 Return to Instructions W W20 OTHER SYMPT COMPLAINTS OF BREAST deleted included in W19 W21 new rubric in ICPC 2 CONCERN BODY IMAGE IN PREGNANCY W77 OTHER NON OBSTETRICAL CONDITION deleted W85 new rubric in ICPC 2 GESTATIONAL DIABETES x X22 new rubric in ICPC 2 CONCERN ABOUT BREAST APPEARANCE X92 new rubric in ICPC 2 CHLAMYDIA INFECTION GENITAL STANDARD PROCESS COMPONENTS OF ICPC 2 Applicable in every chapter Replace dash with Chapter Alpha code The dash shown in first position must be replaced with the appropriate alpha code for each chapter Component 2 DIAGNOSTIC AND PREVENTIVE PROCEDURES 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 Medical Examination Health Evaluation Complete Medical Examination Health Evaluation Partial Pre op check Sensitivity Test Microbiological Immunological Test Blood Test Urine Test Faeces Test Histological Exfoliative Cytology Other Laboratory Test NEC Physical Function Test Diagnostic Endoscopy Diagnostic Radiology Imaging Elec
42. STROINTESTINAL INFECTION D71 MUMPS D72 VIRAL HEPATITIS D73 GASTROENTERITIS PRESUMED INFECTION D74 MALIGNANT NEOPLASM STOMACH D75 MALIGNANT NEOPLASM COLON RECTUM D76 MALIGNANT NEOPLASM PANCREAS D77 MALIGNANT NEOPLASM DIGESTIVE OTHER NOS D78 BENIGN UNCERTAIN NEOPLASM DIGESTIVE D79 FOREIGN BODY IN DIGESTIVE SYSTEM D80 INJURY DIGESTIVE SYSTEM OTHER D81 CONGENITAL ANOMALY DIGESTIVE D82 TEETH GUM DISEASE D83 MOUTH TONGUE LIP DISEASE D84 OESOPHAGUS DISEASE D85 DUODENAL ULCER D86 PEPTIC ULCERS OTHER D87 STOMACH FUNCTION DISORDER D88 APPENDICITIS D89 INGUINAL HERNIA D90 HIATUS HERNIA D91 ABDOMINAL HERNIA OTHER D92 DIVERTICULAR DISEASE D93 IRRITABLE BOWEL SYNDROME D94 CHRONIC ENTERITIS ULCERATIVE COLITIS D95 ANAL FISSURE PERIANAL ABSCESS D96 WORMS OTHER PARASITES D97 LIVER DISEASE NOS D98 CHOLECYSTITIS CHOLELITHIASIS D99 DISEASE DIGESTIVE SYSTEM OTHER Return to Instructions ICPC 2 PLus Users Guide Page 60 F EYE Component 1 Complaints amp Symptoms F01 PAIN EYE F02 RED EYE F03 EYE DISCHARGE F04 VISUAL FLOATERS SPOTS F05 VISUAL DISTURBANCE OTHER F13 EYE SENSATIONS ABNORMAL F14 EYE MOVEMENTS ABNORMAL F15 EYE APPEARANCE ABNORMAL F16 EYELID SYMPTOM COMPLAINT F17 GLASSES SYMPTOM COMPLAINT F18 CONTACT LENS SYMPTOM COMPLAINT F27 FEAR OF EYE DISEASE F28 LIMITED FUNCTION DISABILITY EYE F29 EYE SYMPTOM COMPLAINT OTHER Component 2 Diagnostic Screening amp Preventive Procedures Componen
43. THER P99 PSYCHOLOGICAL DISORDERS OTHER Return to Instructions ICPC 2 PLus Users Guide Page 65 Return to Instructions R RESPIRATORY Component 1 Complaints amp Symptoms R01 PAIN RESPIRATORY SYSTEM R02 SHORTNESS OF BREATH DYSPNOEA R03 WHEEZING R04 BREATHING PROBLEMS OTHER R05 COUGH R06 NOSE BLEED EPISTAXIS R07 SNEEZING NASAL CONGESTION R08 NOSE SYMPTOM COMPLAINT OTHER R09 SINUS SYMPTOM COMPLAINT INCL PAIN R21 THROAT SYMPTOM COMPLAINT R23 VOICE SYMPTOM COMPLAINT R24 HAEMOPTYSIS R25 SPUTUM PHLEGM ABNORMAL R26 FEAR OF CANCER OF RESPIRATORY SYSTEM R27 FEAR OF RESPIRATORY DISEASE OTHER R28 LIMITED FUNCTION DISABILITY RESPIRATORY R29 RESPIRATORY SYMPTOM COMPLAINT OTHER Component 2 Diagnostic Screening amp Preventive Procedures Component 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases R71 WHOOPING COUGH R72 STREP THROAT R73 BOIL ABSCESS NOSE R74 UPPER RESPRATORY INFECTION ACUTE R75 SINUSITIS ACUTE CHRONIC R76 TONSILLITIS ACUTE R77 LARYNGITIS TRACHEITIS ACUTE R78 ACUTE BRONCHITIS BRONCHIOLITIS R79 CHRONIC BRONCHITIS R80 INFLUENZA R81 PNEUMONIA R82 PLEURISY PLEURAL EFFUSION R83 RESPIRATORY INFECTION OTHER R84 MALIGNANT NEOPLASM BRONCHUS LUNG R85 MALIGNANT NEOPLASM RESPIRATORY OTHER R86 BENIGN NEOPLASM RESPIRATORY R87 FOREIGN BODY IN NOSE LARYNX BRO
44. U P 90 APPENDIX C u 99 NW aa H 99 APPENDIX Du ERR 104 FMRC Code Groupers by 2 chapter and componenti 104 APPENDIX E u a E ME CEDE MEE DM DE DM NE ME NE DUM EE MM MED ME 105 FMRC Code Groupers by ICPC 2 Diagnosis 105 Return to Instructions ICPC 2 PLus Users Guide Page 4 SECTION 1 Return to Instructions WORKSHOP REPORT As published in Australian Family Physician Vol 24 No 4 April 1995 pages 612 615 General Practice Medical Records Why code Why classify Helena Britt PhD Director Family Medicine Research Unit Department of General Practice University of Sydney Neil Beaton MBBS MRCGP DA Medical Advisor The Aboriginal Primary Health Care Project Far North Queensland Division of General Practice Graeme Miller MBBS FRACGP Clinical Senior Lecturer Department of General Practice University of Sydney Recently the Information Management Steering Group IMSG a RACGP AMA Commonwealth Government committee responsible for the planning of information management in general practice held a Coding Workshop at which available coding syst
45. YELONEPHRITIS PYELITIS U71 CYSTITIS URINARY INFECTION OTHER U72 URETHRITIS U75 MALIGNANT NEOPLASM KIDNEY U76 MALIGNANT NEOPLASM BLADDER U77 MALIGNANT NEOPLASM URINARY OTHER U78 BENIGN NEOPLASM URINARY TRACT U79 NEOPLASM URINARY TRACT NOS U80 INJURY URINARY TRACT U85 CONGENITAL ANOMALY URINARY TRACT U88 GLOMERULONEPHRITIS NEPHROSIS U90 ORTHOSTATIC ALBUMINURIA PROTEINURIA U95 URINARY CALCULUS U98 ABNORMAL URINE TEST NOS U99 URINARY DISEASE OTHER PREGNANCY CHILDBEARING FAMILY PLANNING Component 1 Complaints amp Symptoms W01 QUESTION OF PREGNANCY W02 FEAR OF PREGNANCY W03 ANTEPARTUM BLEEDING W05 PREGNANCY NAUSEA VOMITING W10 CONTRACEPTION POSTCOITAL W11 CONTRACEPTION ORAL W12 CONTRACEPTION INTRAUTERINE W13 STERILIZATION FEMALE W14 CONTRACEPTION OTHER W15 INFERTILITY SUBFERTILITY W17 POST PARTUM BLEEDING W18 POST PARTUM SYMPTOM COMPLAINT W19 BREAST LACTATION SYMPTOM COMPLAINT W21 CONCERN ABOUT BODY IMAGE RELATED TO PREGNANCY W27 FEAR OF COMPLICATIONS OF PREGNANCY W28 LIMITED FUNCTION DISABILITY PREGNANCY W29 PREGNANCY SYMPTOM COMPLAINT OTHER Return to Instructions Return to Instructions ICPC 2 PLus Users Guide Page 69 Component 2 Diagnostic Screening amp Preventive Procedures Component 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases W70 PUERPERAL
46. an be classified according to standardised systems provided by the Australian Bureau of Statistics ABS However the area presenting the greatest classification problems to primary care providers is clinical information Thinking in terms of the SOAP structure recommended by the RACGP we have a wide range of information which ideally would be classified according to accepted national and international standards Return to Instructions ICPC 2 PLus Users Guide Page 13 Return to Instructions S z Subjective e Patient reasons for encounter the patient expressed reasons for attending on that occasion These may be in terms of the need for a service check up referral etc symptoms headache or a diagnostic label about my diabetes e presenting symptoms information collected by the GP the diagnostic process O Objective findings A Assessment problem label or diagnosis P Plan including prescribing therapies and other treatments While all of these fields should be able to be coded and classified the majority of recent interest has centred on the classification of the patient reasons for encounter the presenting systems and the problem labels or diagnoses When coding one should always keep in mind the purpose Coding should be used to facilitate logical and meaningful data retrieval to find groups of patients for practice audit follow up and recall systems or to gain a view of your practice popul
47. are IC Process PC 9 Component 4 Test results and Component 5 Administrative provide somewhere to put those difficult problem labels which frequently have no pathology eg completing a patient s application for a passport would fall into Component 5 Return to Instructions ICPC 2 PLus Users Guide Page 36 The structure of ICPC represents a move away from the combined anatomical and aetiology based structure of ICD For example where ICD includes a separate chapter for neoplasms one for infections and infestations and another for injuries such problems are distributed among chapters in ICPC depending on the body system to which they belong Regrouping of the rubrics eg for all neoplasms in all body systems can still be undertaken across chapters if analysis of totals is required Grouping is further discussed in Section 5 REFERENCES 1 Lamberts H Woods M eds CPC The international classification of primary care Oxford Oxford University Press 1987 2 A reason for visit classification for ambulatory care Hyattsville MD U S Public Health Service National Centre for Health Statistics DHEW Pub 79 1352 1979 3 Patients reasons for visiting physicians National Ambulatory Medical Care Survey United States 1977 1978 Hyattsville MD Series 13 56 DHS Publications 82 1717 1981 4 Lamberts H Meads S Wood M Results of the international field trial with the reason for encounter classification RFEC Ro
48. ation and its morbidity The classification you choose should therefore have sufficient specificity to allow you to select and save the term you want but not be so specific that it cannot be used with consistency and reliability THE INTERNATIONAL CLASSIFICATION OF DISEASES is the oldest and most widely recognised diagnostic classification available The 9th edition is used widely in the Australian hospital system ICD 9 CM A where trained coders receive paper records from clinicians and secondarily classify the diagnostic data Another revision ICD 10 is to be released in early 1998 after adaptation for Australia Return to Instructions ICPC 2 PLus Users Guide Page 14 Return to Instructions ICD began its development in the late 19th century as an international list of causes of death It therefore has an emphasis on disease in terms of its aetiology pathology and morphology In primary care many of the problems presented and managed remain ill defined at the end of the consultation and it is difficult to classify them in such a disease oriented system In a comparative study of classification systems it was estimated that almost half the problems dealt with in primary care could be not classified with ICD In the late 1980 s when New Zealand family practitioners were told to code using ICD 9 they simply stopped coding because it was far too difficult All looked forward to the new version ICD 10 which was said to overcome this
49. ation for general family practice and primary care and has been used extensively in some parts of the world notably in Europe and Australia 22 CPC was first published in 198720 This is now referred to as ICPC 1 In 1993 it was included in a publication about its use in Europe19 This is referred to as ICPC E This 1998 publication is referred to as ICPC 2 ICPC is used when referring to the generic classification Classifications for primary care Classifications for primary care have a number of requirements which differ from those of other branches of medicine because of the different spectrum of conditions seen and the different diagnostic and management processes involved The classification must cover the full spectrum of conditions treated including undifferentiated complaints and symptoms health promotion and prevention as well as a full range of specified diseases Abdominal pain should be reportable as abdominal pain and not for example as appendicitis simply because there is nowhere else to include it Return to Instructions ICPC 2 PLus Users Guide Page 31 Return to Instructions Conditions must be able to be determined on clinical grounds without requiring distinctions to be made by inappropriate sophisticated investigations or even worse by requiring knowledge of the underlying pathogy The classification should be logical and based on recognised criteria such as body systems so that every co
50. be gained to that term vira illness and disease Therefore while each term within any one ICPC rubric has a unique code a GP may on different occasions use different keys to access that term The GP may choose to describe a single medical concept in different terms on specific occasions e g Diabetes Type l and Insulin dependent diabetes and his her term selection should be saved in the medical record not changed to the description of the ICPC rubric Note that the terms are listed in term code order which is derived purely from the order of entry There is only one term code per term irrespective of the number of keywords New keywords and additional codes are being added and will continue to be added on request In ICPC PLUS as in any other indexed system a single keyword can lead to multiple concepts and at times to multiple ICPC rubrics and these should be offered as a pick list For example if you enter the term diab or diabetes the picklist all the terms attached to diabetes in the second column in Figure 4 2 should appear together with others such as diabetes in pregnancy which do not belong with code T90 The concept follows that used in the Read Clinical Codes For the clinician the exercise is one of terming rather than coding What secondary coders do i e medical records coding clerks in hospitals is find the recorded medical term and allocate the correct code to the term In contrast this system allows t
51. been added after a 40 million project in which 40 professional colleges designed a term set for its specialty It has 250 000 terms organised in a hierarchical structure one could describe as a tree Classifications can be laid over the top of the terms so you can analyse data almost any way you wish However it is not yet in widespread practical use Software systems using Read 3 are still under development Some feel that general practice terms have been somewhat lost in the mire THE INTERNATIONAL CLASSIFICATION OF PRIMARY CARE ICPC In the 50 s and 60 s a number of countries including Canada and the UK attempted to develop new classifications specifically for primary care In the early seventies the newly formed Classification Committee of the World Organisation of Family Doctors WONCA decided it was time to develop a new international classification for primary care This resulted in the International Classification of Health Problems in Primary Care ICHPPC the second version having the added advantage of inclusion and exclusion criteria However it still lacked sufficient codes for ill defined conditions and patient expressed reasons for encounter largely because it retained the ICD structure which confined its flexibility In 1978 WHO set up a working party to develop a classification system for patient reasons for encounter Most of its members were also members of WONCA This work resulted in the International Classifica
52. but the most important issues are e breadth of coverage of primary care e ease of access to the required term e national and international acceptance and comparability e ease of sorting the information for analysis and identification of patient groups Note that the classification you choose should be mapped with authorisation to ICD 9 CM A and later to ICD 10 if transfer of information across the health care system is ever to come to pass The computerisation of primary care is at the beginning of an exponential curve Any acceptable classification system will cost you money Think before you buy About the Author Helena Britt is a Senior Research Fellow and the Director of the Family Medicine Research Unit Department of General Practice University of Sydney She is a clinical psychologist with over twenty years research experience the majority in health services research in general practice Her interests centre in improved information management and analytical techniques in primary care and the classification of clinical data Return to Instructions ICPC 2 PLus Users Guide Page 23 Return to Instructions References 1 Regan B Ireland M Inappropriateness of coding systems for recording clinical data Informaitcs in Healthcare Australia 1994 3 3 101 4 Britt H Recording clinical data the advantages of coding a response Informatics in Healthcare Australia 1994 3 4 149 152 Britt H
53. ch as a body system heading The decision of which coding system must be determined by the level of detail required at the first entry point in this case the patient medical record Where the chosen classification does not suit all needs multiple systems can be utilised through a process of mapping This is the process of working out the relationship between individual codes in each of the systems Usually the more detailed system is mapped to the less detailed Thus a group of codes or multiple individual codes from a variety of sections in one system may be placed together under one code in another The majority of internationally recognised classifications are mapped to multiple other classifications For example the International Classification of Primary care has a body system based structure and is ideal for population based general practice data analysis The International Classification of Diseases has a disease based structure far more specific codes and is designed for hospital data systems The latter is mapped Return to Instructions ICPC 2 PLus Users Guide Page 10 Return to Instructions to the former so that data collected in terms of ICD can be analysed in terms of ICPC Another example is the Read Clinical codes which are mapped to both ICD 9 and to ICPC The mapping process is the responsibility of the classification designer and allows people using different classification systems possibly at diffe
54. dney in co operation with World Organisation of Family Doctors WONCA ICPC 2 PLus Users Guide Page 1 ICPC 2 PLUS Family Medicine Research Centre World Organisation of National Colleges Academics and Associations of General Practitioners Family ICPC 2 Physicians 1998 ICPC 2 PLUS and ICPC 2 PLUS User s Guide 0 O University of Sydney 1998 8 Family Medicine Research Centre All rights reserved No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any means electronic mechanical photocopying recording or otherwise without the prior permission of the Family Medicine Research Centre University of Sydney ICPC 2 PLus Users Guide Page 2 Return to Instructions The International Classification of Primary Care ICPC 2 Copyright 1987 WONCA ICPC 2 PLUS Copyright 1994 by the Family Medicine Research Centre University of Sydney All rights reserved No part of this publication may be reproduced stored on a retrieval system or transmitted in any form or by any means electronic mechanical photocopying recording or otherwise without prior written permission from the Family Medicine Research Centre University of Sydney For information address the Family Medicine Research Centre Department of General Practice University of Sydney Acacia House Westmead Hospital WESTMEAD NSW AUSTRALIA 2145 Telephone 02 9845
55. e being increasingly adopted by general practitioners throughout the world particularly in the fast growing number of practices utilising computerised medical records The advantages of coding data at the point of entry have been outlined in this paper and general practitioners in Australia should consider these points when thinking of using computers whether for full medical records recall systems direct printing of prescriptions or age sex disease registers The implications for later meaningful data retrieval to assist practitioners in the provision of quality care for their patients are enormous References 1 Dick SR Steen EB ed The computer based patient record an essential technology for health care Institute of Medicine National Academy Press Washingtom DC 1991 Regan B Ireland M Inappropriateness of coding systems for recording clinical data Informatics in Healthcare Australia July 1994 3 2 101 014 Wood M Lamberts H Meijer JS Hofmans Okkes IM The conversion between ICPC and ICD 10 Requirements for a family of classification systems in the next decade Fam Pract 1992 9 340 348 WHO ed International classification of diseases 9th revision Geneva World Health Organisation 1977 Weed LL Hertzberg R Clinical application of medical software for problem solving in ambulatory care J Ambulatory Care Manage 1985 8 66 83 Return to Instructions ICPC 2 PLus Users Guide Page 12 A
56. eds Role of Informatics in Health Data Coding and Classification Systems Amsterdam Elsevier Sci Publ JFIP JMIA 1985 Bentsen BG International Classification of Primary Care Scandinavian J Primary Care 1986 4 43 56 Lamberts H Wood M Hofmans Okkes eds The International Classification of Primary Care in the European Community with Multi Language Layer Oxford Oxford University Press 1993 Lamberts H Wood M eds ICPC International Classification of Primary Care Oxford Oxford University Press 1987 Bridges Webb C Britt H Miles DA Neary S Charles J Traynor V Morbidity and treatment in general practice in Australia 1990 1991 Med J Aust 1992 157 Supp 19 Oct S1 S56 ICPC 2 PLus Users Guide Page 33 SECTION 3 Return to Instructions THE INTERNATIONAL CLASSIFICATION OF PRIMARY CARE STRUCTURE AND DERIVATIVES This section has largely been drawn from Lamberts H Wood M eds ICPC International Classification of Primary Care Oxford Oxford University Press 1987 Though ICPC was primarily designed for the classification of patient reasons for encounter RFEs by the primary care provider at the time of the consultation it can also be applied to the provider s assessment of the problem diagnoses and to the diagnostic and therapeutic interventions utilised at the encounter Patient reasons for encounter RFEs are very different from the diagnoses or problems managed For an adequate description of
57. eg diabetes hypertension amenorrhoea general check up The problem title should not be recorded as test results In the above example the problem label may be question of pregnancy or late menses or Note 2 is not designed to code the drug prescribed However we are developing drug classification which will be offered to GPs when available Question Could you please include severity levels for some diseases e g COAD and more detail about site location for others Answer While it is possible to add this more specific information and provide a specific code for different severity levels or for site this would enlarge ICPC 2 PLUS by about three or four fold One of the advantages of ICPC 2 PLUS over systems such as Read Clinical Codes or ICD9 CM is its size The more codes we introduce the more difficult it becomes to find the term required as the pick list become longer In deciding on the level of detail to be included in ICPC 2 PLUS we have constantly kept in mind that the main use of a hierarchical coding system is for getting the data out in a meaningful manner E g you may wish to identify all your patients who have presented with an injury You may wish to further group these patients into sub groups such as fractures and still further into fractures of the ulna Ideally you may like to differentiate between fractured mid shaft ulna versus those with a fractured proximal
58. eleted included in A16 CONCERN ABOUT APPEARANCE RISK FACTOR FOR MALIGNANCY RISK FACTOR NOS ALLERGY ALLERGIC REACT transfer from A12 HEALTH MAINTENANCE PREVENT MED deleted included in B02 deleted included in A91 deleted included in B99 DYSPEPSIA INDIGESTION transferred to D96 HEPATOMEGALY transferred to D23 WORMS OTHER PARASITES ICPC 2 PLus Users Guide Page 55 K K22 new rubric in ICPC 2 K74 ANGINA PECTORIS K76 OTHER AND CHRONIC ISCHAEMIC HEART DISEASE K80 ECTOPIC BEATS ALL TYPES K81 HEART MURMER NOS K91 ATHEROSCLEROSIS K91 altered rubric in ICPC 2 K92 OTHER ARTERIAL OBSTRUCTION L L05 FLANK SYMPTOMS COMPLAINTS L06 AXILLA SYMPTOMS COMPLAINTS L71 NEOPLASMS L83 SYNDROMES RELATED TO CERVICAL SPINE L84 OSTEOARTHRITIS OF SPINE L86 LUMBAR DISC LESION BACK PAIN L87 GANGLION JOINT TENDON L97 CHRONIC INTERNAL KNEE DERANGEMENT included with L99 in ICPC 2 N N02 TENSION HEADACHE NO08 new rubric in ICPC 2 N80 OTHER HEAD INJURY WYO SKULL FRACTURE N95 new rubric in ICPC 2 P P21 OVERACTIVE CHILD HYPERKINETIC P75 HYSTERICAL HYPOCHONDRIACAL DISEASE P77 SUICIDE ATTEMPT P81 new rubric in ICPC 2 P82 new rubric in ICPC 2 P86 new rubric in ICPC 2 R R22 SYMPTOM COMPLAINT TONSILS R70 TUBERCULOSIS R72 STREP THROAT SCARLET FEVER R79 new rubric in ICPC 2 R80 INFLUENZA WITHOUT PNEUMONIA R82 PLEURISY R93 R91 CHRONIC BRONCHITIS R92 new rubric in ICPC 2
59. ems and their application in general practice computerised medical records were reviewed As there has been in the past some discussion as to the value of coding the workshop participants agreed that a paper outlining the reasons for coding and classifying clinical data should be prepared and disseminated to all general practitioners Return to Instructions Over 95 million general practice service rebates are claimed through Medicare every year These services are provided by over 20 000 medical practitioners including 16 000 recognised general practitioners Eighty two percent of the population visit a general practitioner at least once a year and each patient visits a GP an average five times per year data obtained for the General Practice Branch Department of Human Services and Health However the management of the information recorded in the course of these services is generally poor As a result very little of this large data Return to Instructions ICPC 2 PLus Users Guide Page 5 source provides information which is useful to general practitioners for comprehensive and continuing patient and community care Clinicians need reliable clinical data to provide quality patient management for patient audit for quality assurance and for practice management Group information for the practice or the community also aids the management of specific groups of patients Further data collected for the primary purpose of patient ca
60. eric For example Allerg will pick up lists for both allergic and allergy Hypertensi will pick up a list which includes hypertension and hypertensive Infecti will pick up a list which includes infections infective infectious etc Degenerat will pick up degeneration and degenerative Diabet will pick up diabetes and diabetic Of course as you get to know the range of terms in the database you will learn to enter infection in full when you specifically do not want the choice of infective options on your pick list Allergies and sensitivities If you are using ICPC 2 PLUS to record allergies and sensitivities in a patient medical record or summary sheet a variety of key words may be used such as allerg allergic reaction adverse effect sideeffect SE Furthermore if the allergy sensitivity is related to antibiotics the generic drug name may be used as a key word eg Penicillin for Amoxycillin Abbocillin etc Cephalosporin for Keflex Ceclor etc Macrolide for Erythromycin Rulide etc Return to Instructions ICPC 2 PLus Users Guide Page 51 Return to Instructions Question How do find an ICPC 2 PLUS code for repeat scripts as a problem Answer Code 50 replace the dash with the associated ICPC 2 chapter does allow the coding of repeat script s as a diagnosis So if you enter script as the keyword you will be offered a picklist of body systems to which t
61. from a nomenclature or coding system A medical nomenclature is a list or catalogue of approved terms for describing and recording clinical and pathological observations It should be extensive so that any morbid condition that can be separately described has a specific designation Classification is a method of generalisation to obtain data about groups of cases rather than individual occurrences The categories should be chosen so that they will facilitate the statistical study of disease phenomena grouping like with like A specific disease entity should have a separate title in the classification only when its separation is warranted because of the frequency of its occurrence or its importance as a morbid condition Many titles in the classification will refer to groups of separate but related morbid conditions Return to Instructions ICPC 2 PLus Users Guide Page 25 Return to Instructions It is the grouping of with which is the essential feature of a classification If this is done in a hierarchical way with varying levels of specificity eg diseases of the respiratory tract diseases of the lung pneumonia lobar pneumonia continuing into great detail then a comprehensive classification such as ICD can be used in its most detailed form as a nomenclature However an alphabetical list of conditions in a nomenclature cannot act as a classification Labelling aspects of general family practice such as reasons for encou
62. future is being considered by the FMRC Your input is extremely useful in the maintenance and ongoing development of ICPC 2 PLUS Return to Instructions ICPC 2 PLus Users Guide Page 54 SECTION 6 Return to Instructions THE INTERNATIONAL CLASSIFICATION OF PRIMARY CARE 2 SUMMARY OF MAIN CHANGES TO COMPONENTS 1 AND 7 FROM ICPC 1 TO ICPC 2 Only major changes are listed here additions change in meaning of the rubric or transfer or deletion of a rubric There are many other changes of detail to the titles of the rubrics which do not change the meaning and are not listed here CODE TITLE ICPC 1 A A05 GENERAL DETERIORATION A11 omitted by mistake from ICPC A12 ALLERGY ALLERGIC REACTION A13 CONCERN ABOUT DRUG REACTION A14 INFANTILE COLIC A15 EXCESSIVE CRYING INFANT A17 OTHER GEN SYMPT INFANT A18 new rubric in ICPC 2 A21 new rubric in ICPC 2 A23 new rubric in ICPC 2 A92 TOXOPLASMOSIS deleted included with A78 A98 new rubric in ICPC 2 B B03 OTHER SYMPT LYMPH GLANDS B85 UNEXPLAINED ABNORMAL BLOOD TEST B86 OTHER HAEMATOLOGICAL ABNORMALITY D D07 new rubric in ICPC 2 D22 WORMS PINWORMS OTHER PARASITES D23 transferred from D96 D96 HEPATOMEGALY D96 changed rubric in ICPC 2 Return to Instructions CODE TITLE ICPC 2 some abbreviated FEELING ILL CHEST PAIN NOS transferred to A92 CONCERN FEARABOUT TREATMENT deleted included in DO1 deleted included in A16 d
63. g bag codes such as other diseases of the respiratory system or other digestive symptom e The published version of ICPC now out of print has a poor index Therefore when a practitioner cannot find the term in the index s he has to make a decision about where it should best be classified This leads to a lack of coding reliability which has repercussions when you later wish to later compare data from multiple sources e For computerised clinical systems the disk copy of the book lacks sufficient specificity for medical records or even for disease registers and recall systems A prime example is all types of diabetes are grouped in one rubric diabetes yet for quality care for legal reasons and for sheer convenience you need to have recorded IDDM or NIDDM in the patient s record not just diabetes Another example is the combination of HIV and AIDS together in one code e Like ICD it is a static system which is only reviewed each decade Return to Instructions ICPC 2 PLus Users Guide Page 19 Return to Instructions ICPC PLUS Recognising the advantages of ICPC as an analytical tool and its disadvantages in terms of its lack of specificity for clinical systems the Family Medicine Research Unit University of Sydney developed an extended version of the ICPC The extension was based on data recorded by GPs about more than 800 000 GP patient encounters collected during the Australian Morbidity and Treatment Survey AMTS
64. ganisation of Family Doctors release of a revised edition of ICPC the Family Medicine Research Unit has created a second version of ICPC PLUS namely ICPC 2 PLUS This new revised version was developed with continued consultation with the Chairman of the WONCA classification committee It maintains its predecessors structure of terms and process of keyword allocation approach to classification as a terming rather than coding process Development of ICPC 2 PLUS The conversion process from ICPC PLUS to ICPC 2 PLUS was a 3 stage process due to the significant changes in the structure of ICPC 2 A number of ICPC rubrics were deleted in ICPC 2 and a number of new rubrics were added to the classification Firstly the final version of ICPC PLUS was copied into a new database that contained ICPC 2 s structure and revised rubrics ICPC PLUS terms located in rubrics that had been deleted in ICPC 2 were then moved to applicable ICPC 2 rubrics and their path mapped Finally all new ICPC 2 rubrics were identified and terms added to them In particular there were significant additions made in the areas of therapeutic and diagnostic procedures psychological counseling and referrals to specialists and allied health professionals Map creation Through this entire process of term movement a map was developed to convert retrospective data collected by End Users of ICPC PLUS into ICPC 2 PLUS Such a map allows users to access all information previously collec
65. he drug prescribed relates e g prescription respiratory Question What do do when can t find the term want Answer After considering spelling keyword length and term organisation if you still can t find the term you want In each software product there should be a facility to enter the term in free text and apply a temporary code J99 The term you record should be retained in the database and allocated a term code so that the first time you use J99 the term you record will be saved as term number J99 001 and so on Your software should allow you to view your list of temporary terms You could print out the list and post or fax it to the Family Medicine Research Centre so that the terms can be allocated to the correct ICPC 2 code and added to ICPC 2 PLUS with their term keys The next upgrade you receive will therefore include the term the correct code and term code Your software should allow you to alter your original record to the correct code of course always retaining the hidden audit trail of the change for medico legal purposes Question What do do when change a diagnosis Answer This question brings up the concept of problem linkage over time through changes in diagnosis For example A patient presents with a headache the problem is entered as headache At a later date you decide that these headaches could more specifically be described as Migraine headaches which has a different code in
66. he practitioner to select the TERM most suitable to his her needs from the pick list The computer transparently attaches the correct ICPC code for the concept and the code number of the selected term i e terming rather than coding To all intents and purposes you should be relatively unaware of the coding process Distribution of ICPC ICPC 2 Permission was sought from WONCA to offer the database to software houses for wider application in general practice While some GPs were already using ICPC in non commercial GP data systems in the main they were using unlicensed copies of ICPC Further in many cases they used idiosyncratic adaptations which resulted in non comparable data In an effort to improve the standardised use of the classification and to ensure copyright of the ICPC ICPC 2 was upheld WONCA provided the FMRU with the exclusive license for the distribution of ICPC ICPC 2 in electronic form in Australia and the Pacific Basin Return to Instructions ICPC 2 PLus Users Guide Page 42 Return to Instructions ICPC 2 PLUS ICPC PLUS broke new ground when it was first released in 1991 It was the first computerised classification system that had been specifically designed for Australian general practice and primary care It has been implemented by a number of software suppliers in clinical systems across the nation and has an End User base that is rapidly growing and diversifying With the advent of the World Or
67. idemiological data analysis However in the absence of any other acceptable classification system the unit came under increasing pressure from GPs to adapt ICPC for computer usage in the clinical primary care setting One of the major problems with using ICPC for computerised medical systems was its lack of specificity in some areas For epidemiologists it may be adequate to count the number of patients or encounters with an other viral illness i e the number of A77 s that arise However in a clinical setting the practitioner must be able to differentiate between the 33 viral illnesses which fall into this rubric A77 Other viral illness For Example if you practice in one of our sub tropical areas it may be very important to be able to identify the patients who are suffering specifically from Ross River Fever not just other viral illness There are two ways around the problem neither ideal 1 Select all records including A77 then use a word search engine to find all records involving Ross River Fever and hope you have never mis spelt it 2 Create another level in the hierarchy When developing ICPC PLUS a computerised classification system derived from ICPC some users of ICPC suggested that further hierarchical layers should be added for increased specificity However ICPC was not designed for such extension Using hypertension as an example a possible hierarchy may have one code at the upper level for hypertensio
68. ion 1992 International Classification of Health Problems in Primary Care ICHPPC Chicago World Organization National Colleges Academies and Academic Associations of General Practitioners Family Physicians WONCA American Hospital Association AHA 1975 ICHPPC 2 International Classification of Health Problems in Primary Care Oxford Oxford University Press 1979 ICHPPC 2 Defined International Classification of Health Problems in Primary Care 3rd edition Oxford Oxford University Press 1983 Report of the International Conference on Primary Care Alma Ata USSR 6 12 September 1978 WHO Alma Ata 78 10 Meads S The WHO Reason for Encounter classification WHO Chronicle 1983 37 5 159 162 Lamberts H Meads S and Wood M Classification of reasons why persons seek primary care pilot study of a new system Public Health Reports 1984 99 597 605 Lamberts H Meads S and Wood M Results of the international field trial with the Reason for Encounter Classification RFEC Med Sociale Preventive 1985 30 80 87 Working Party to develop a classification of the Reasons for Contact with Primary Health Care Services Report to the World Health Organization Geneva Switzerland 1981 Wood M Family medicine classification systems in evolution J Fam Pract 1981 12 199 200 Lamberts H Meads S and Wood M Results of the field trial with the Reason for Encounter Classification RFEC In Cote RA Protti AJ and Scherner JR
69. l to Other Provider Nurse Therapist Social Worker EXCL M D 67 Referral to Physician Specialist Clinic Hospital 68 Other Referrals NEC Assist at operation 69 Other Reason for Encounter NEC A GENERAL amp UNSPECIFIED Component 1 Complaints amp Symptoms A01 PAIN GENERAL MULTIPLE SITES A02 CHILLS A03 FEVER A04 WEAKNESS TIREDNESS GENERAL A05 FEELING ILL A06 FAINTING SYNCOPE A07 COMA A08 SWELLING A09 SWEATING PROBLEMS A10 BLEEDING HAEMORRHAGE NOS A11 PAIN CHEST NOS A13 CONCERN FEAR ABOUT TREATMENT A16 IRRITABLE INFANT A18 CONCERN ABOUT APPEARANCE A20 EUTHANASIA REQUEST DISCUSSION A21 RISK FACTOR FOR MALIGNANCY A23 RISK FACTOR NOS A25 FEAR OF DEATH DYING A26 FEAR OF CANCER NOS 27 FEAR OF OTHER DISEASE NOS A28 LIMITED FUNCTION DISABILITY NOS A29 GENERAL SYMPTOM COMPLAINT OTHER Component 2 Diagnostic Screening amp Preventive Procedures Component 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases ATO TUBERCULOSIS AT1 MEASLES AT2 CHICKENPOX AT3 MALARIA A74 RUBELLA A75 INFECTIOUS MONONUCLEOSIS A76 VIRAL EXANTHEM OTHER Return to Instructions A77 VIRAL DISEASE OTHER NOS ICPC 2 PLus Users Guide Page 58 AT8 INFECTIOUS DISEASE OTHER NOS AT9 MALIGNANCY NOS A80 TRAUMA INJURY NOS A81 MULTIPLE TRAUMA INJURIES A82 SECONDARY EFFECT OF TRAUMA A84
70. ld be included and select these term codes for inclusion in the analysis For example You wish to send a recall letter to all patients who require DPT immunisations review the list of all terms for 44 and select those which you feel should be included in this sub group If the software allows you could select on a variety of other fields as well e g all female patients aged 0 6 years REFERENCES 1 Bridges Webb C Britt H Miles DA Neary S Charles J Traynor V Morbidity and treatment in general practice Med J Aust 1992 157 19 Oct Spec Supl S1 S56 Return to Instructions ICPC 2 PLus Users Guide Page 45 SECTION 5 Return to Instructions HINTS FOR USING ICPC 2 PLUS Getting Started Firstly to get a feeling for the classification you are about to use read the background particularly the structure of the coding frame Sections 3 amp 4 Terming with ICPC 2 Plus ICPC 2 PLUS utilises a technique of terming rather than coding to summarise data Terming refers to the entry of a few key letters or a brief Keyword to access a picklist of possible terms which may be used to describe a particular medical concept see over When a term is selected the computer transparently attaches the correct ICPC 2 PLUS code number In contrast cod mg is a much more laborious task which involves interpretation of the medical record looking up selecting and applying the most appropriate code
71. le of informatics in health data coding and classification systems Amsterdam Elsevier Sci Publications 1985 5 Meads S The WHO reason for encounter classification WHO Chronicle 1983 37 159 162 6 Lipkin M and Kupka K eds Psycho social factors affecting health New York Praeger 1982 7 WHO Psychological factors affecting health assessment classification and utilisation Report of the World Health Organisation on the Bellagio Conference Geneva WHO 1980 8 WHO International classification of diseases 9th revision Geneva World Health Organisation 1977 9 WONCA Classification Committee C Process PC International classification of process in primary care Oxford Oxford University Press 1986 Return to Instructions ICPC 2 PLus Users Guide Page 37 SECTION 4 Return to Instructions ABOUT ICPC 2 PLUS This section has been based on the following paper Development of a database for the International Classification of Primary Care for direct entry H Britt Presented to the 14th WONCA WORLD CONFERENCE Hong Kong June 1995 Background to ICPC PLUS The International Classification of Primary Care or ICPC was designed by the WONCA Classification Committee primarily for use by the health care provider at the time of the consultation on paper based records The Family Medicine Research Unit FMRU University of Sydney has however used it in the centralised coding of patient reasons for encounter R
72. list of patients having that entry Alternatively you may wish to identify the ICPC 2 code for uncomplicated hypertension K86 and then ask for the list of all records having that code attached Sorting at multiple rubric level While it is useful to be able to sort your stored data at individual rubric level as above sometimes you may want to identify a group of patients who have any one of multiple diagnoses or symptoms Example 1 You want to identify all patients in the practice who have attended for uncomplicated hypertension K86 hypertension with complications K87 and elevated blood pressure without diagnosis of hypertension K85 You would search for all records which include any one of these three codes Example 2 When viewing the relative frequency of presentations of rash there are two symptom codes available to represent this concept localised skin rash coded as S06 and generalised skin rash coded as 507 If you wanted to identify all the patients who had presented with skin rash generalised or localised both codes would need to be searched For these more general concepts which involve multiple ICPC 2 rubrics you can also utilise the list of Code Groupers provided in Section 5 to ensure all cases will be selected These code groupers have been provided to software developers so you should be able to view the grouper list on your computer or select them automatically if your software allows Return to Instructio
73. lling into each sub group varied between chapters This meant that analysis of a sub group across chapters eg all injuries all neoplasms could not be undertaken by a simple selection of common numerals across all chapters A detailed review of the component breakdown was undertaken and under the guidance of the Chairman of the WONCA Classification Committee rubrics were re allocated to their correct component and a more detailed component breakdown created The new categorisation includes eleven components the original diagnostic component component 7 having been further broken down into the sub groups mentioned above A chart of the new components by chapter including lists of all codes which should be included in each cell is shown in your User Guide This chart has been supplied to all software developers utilising ICPC 2 and should therefore be included in your program in some form Some examples of analyses using chapter component combinations are All patients treated for any injury over the past year All chapters Component 10 e All patients managed for an infection of the skin Chapter S Comp 8 in the last month e All male patients managed for a male genital disease Chapter Y component 7 made up of components 8 12 Analysis using part of an ICPC rubric When you are only interested in one part of an ICPC rubric first view the list of terms available with their varied term keys select all those which you feel shou
74. mework it did not include inclusion criteria for the rubrics or any cross referencing It was thus in this respect less useful than the previous publication ICHPPC 2 defined though it referred to it as a source of inclusion criteria which could e used In 1985 a project began in a number of European countries to use the new classification system to produce morbidity data from general practice for national health information systems This involved translations of the classification and comparative studies across countries The results were published in 1993 in a book including an update of ICPC In 1980 WONCA became a Non Government Organisation NGO in official relations with WHO and joint work together since has led to a better understanding of the requirements of primary care for its own information systems and classifications within an overall framework encompassing all health services The International Classification of Primary Care ICPC The International Classification of Primary Care ICPC broke new ground in the world of classification when it was published in 1987 by WONCA the World Organisation of National Colleges Academies and Academic Associations of General Practitioners Family Physicians now known more briefly as the World Organisation of Family Doctors For the first time health care providers could Classify using a single classification three important elements of the health care encounter reasons for encoun
75. n not otherwise stated The next level may be defined as primary or secondary At the third level it may be benign or malignant and at the fourth level with without target organ involvement see Figure 4 1 Specific target organ involvement could be differentiated at the next level Return to Instructions ICPC 2 PLus Users Guide Page 39 Return to Instructions In ICPC there are already two codes for hypertension one without complications and one with involvement of target organs Both of these rubrics cross multiple levels of the hierarchy FIGURE 4 1 A possible hierarchy for the diagnosis of hypertension HYPERTENSION not otherwise stated a PRIMARY SECONDARY Benign Malignant Malignant Non malignant No T T No involved target involved target involved target involved target organs organs organs organs Extension of the hierarchy is further complicated by lack of agreement about definitions and synonymous terms even within one country Using Diabetes as an example see Figure 4 2 we could probably gain clinician consensus that Type l diabetes is synonymous with insulin dependent diabetes and that IDDM is an acceptable acronym that Type II diabetes is synonymous with non insulin dependent diabetes and NIDDM is an acceptable acronym However the extent to which the remaining terms listed in Figure 4 2 are synonymous with either of these labels is questionable Some people would state that juvenile onse
76. n 04 01 KEYWORD ABBREVIATIONS To facilitate fast and easy access to terms the latest version of ICPC 2 PLUS includes many new abbreviations as keywords The list of abbreviations available in ICPC 2 PLUS is attached Where an acronym is not a recognisable part of a word eg CCF COPD you will find you gain speedy access to a very short picklist However where the acronym can form part of a word it will not provide a mutually exclusive picklist of terms attached to that acronym It will give you a picklist of terms attached to the acronym and those linked to keywords beginning with the same letters For example if you enter CAL chronic airways limitation as a keyword your picklist will consist of terms associated with keywords beginning with CAL i e keywords such as calculus callosite callus and calf In most cases however the picklist provided will be significantly shorter than previous access routes Please continue to notify us of other commonly used abbreviations to be considered for inclusion Your suggestions are extremely valuable The Keyword Abbreviations List has been removed from THIS electronic version The Full APPENDIX B is included in the hardcopy version sent to licensed users Return to Instructions ICPC 2 PLus Users Guide Page 90 Appendix C Return to Instructions New Terms APPENDIX C Version 07 2003 NEW TERMS Since the last release a number of new terms have been added to ICPC 2 PLUS
77. n additional chapter for psychological problems and one for social problems Each chapter is identified by a single alpha code which is the first character of all rubrics belonging in the chapter Figure 3 1 Each chapter is divided into seven components identified by a range of two digit numeric codes which are not always uniform across chapters Figure 3 1 Structure of ICPC Chapters Components US 1 Symptoms complaints EBENEN 2 Diagnostic screening prevention 3 Treatment procedures medication 5 Administrative Amas j A General L Musculoskeletal U Urinary B Blood blood forming N Neurological W Pregnancy family planning D Digestive P Psychological X Female genital F Eye R Respiratory Y Male genital H Ear S Skin Z Social K Circulatory T Metabolic endocrine nutrition Return to Instructions ICPC 2 PLus Users Guide Page 35 Return to Instructions Component 1 provides rubrics for symptoms and complaints It drew on the National Ambulatory Medical Care Survey Reason for Visit Classification NAMCS RFV 2 3 and on the RFE C developed by the WHO working party 2 4 5 Rubrics in this component can be used to describe presenting symptoms and are valuable for describing the problem under management in a problem list in the medical record when the condition is as yet ill defined eg general ill feeling feeling tired Component 7 is the diagnoses disease component in each chapter This component will
78. n to Instructions ICPC 2 PLus Users Guide Page 27 Return to Instructions Until the mid 1970 s most morbidity data collected in primary care research was classified using the International Classification of Diseases ICD This had the important advantage of international recognition aiding comparability of data from different countries However there was the disadvantage that the many symptoms and non disease conditions that present in primary care were difficult to code with this classification originally designed for application to mortality statistics and with a disease based structure The Classification Committee of the World Organisation of National Colleges Academies and Academic Associations of General Practitioners Family Doctors WONCA first met in 1972 in Melbourne at the time of the inauguration of WONCA Many of its members had already been corresponding for some years about morbidity classifications for general practice The Committee agreed that it was time to design a classification specifically for primary care Recognising the problems of the ICD and the need for an internationally recognised classification for general practice the WONCA Classification Committee designed the International Classification of Health Problems in Primary Care ICHPPC first published in 1975 with a second edition in 1979 related to the 9th revision of ICD Although this provided a section for the classification of some undiagn
79. ndicectomy in the History section it clearly indicates it has been done in the past If you record it in the Problem list it suggests you personally undertook an appendicectomy as part of the management of a problem i e appendicitis Return to Instructions ICPC 2 PLus Users Guide Page 49 Return to Instructions Question How do find a code for pregnancy results in my problem list Answer Enter pregnancy results or test Your picklist will offer a choice one of which is W60 Test results pregnancy together with others specifically attached to a body system However in a problem based medical record there should never be a diagnosis problem labelled in this manner If a patient rings and asks for repeat scripts for multiple problems each repeat should be recorded within the problem to which it is linked e g Patient requests repeat scripts for hypertension and the pill You saw the patient recently and you do not need to see her again at this time Within the patient s record the problem list should already include problems called oral contraception and hypertension You need to enter the Pill linked to the oral contraception and enter the anti hypertensive against the hypertension The pregnancy test should be recorded as part of the process of care Using the same argument if a patient returns for test results the problem you are managing is still the one for which you requested the tests
80. ndition has only one logical place This is not the case with ICD where the main groupings chapters include body systems aetiology and patient age with the result that influenza could as logically be in the infection chapter as in the respiratory chapter and all perinatal conditions in any body system are grouped in one chapter The classification should be hierarchical allowing entry of data at a specific level when indicated eg adeno carcinoma of the colon or at a much less specific level bowel cancer when either the clinical condition is not yet clear or the purpose of the data recording does not require detail The more specificity required the less reliable is the data Finally the classification should have clear outlines and rules so that users appreciate how conditions are related within it This means that the basic structure should not be too extensive and the classification not too large No one classification meets all these requirements Even if one did it would not necessarily be ideal for all purposes It is however important in the interests of comparability of data particularly but not only on an international basis to use classifications which have a defined relationship to others especially to the most used ICD The narrow pathological basis of ICD has been considerably widened in the 9th and 10th revisions the latter now including in its title diseases and related health problems However it is far from easy
81. ng it is presently being mapped to ICD 9 CM A so that data from different sources can be compared ICPC PLUS is distributed by the Family Medicine Research Unit OTHER SYSTEMS There are some other coding systems which should be mentioned for completeness SNOMED is an internationally designed classification with its origins in pathology It works on a combination of pathophysiology histopathology and anatomical site It is a constructionist model which allows the development of highly specific codes which may be extremely useful in pathology The level of specificity it allows goes far beyond the interests of primary care Further the system allows you to build nonsensical constructs such as broken heart fractured eye Its structure may be suitable to the reductionist theory of specialist practice but is the very antithesis of holistic care Further while SNOMED has enthusiastic supporters throughout the world it is not widely used in general practice Return to Instructions ICPC 2 PLus Users Guide Page 21 Return to Instructions UMLS Universal Medical Language System is strictly speaking a database access system not a classification The database includes both medical and scientific terms It originated with the keywords from Medline and recently the terms used in many classification systems have been added It is a search engine which was designed to contain sufficient terms including words such as aluminium
82. ns ICPC 2 PLus Users Guide Page 44 Return to Instructions Revised components Analysing your records by CHAPTER COMPONENT Groupers you can identify the codes to be included when analysing on the basis of broader medical constructs As described in Section 3 the ICPC 2 is divided into seven components which are common to all chapters only components 2 6 being made up of rubrics which can be applied equally in all chapters Components 1 symptoms and 7 diagnoses differ in each chapter according to the most frequent symptoms and diagnoses which occur in each body system or psychosocial area While working with ICPC 2 it became clear to the Family Medicine Research Unit that the division between the two components was not always correct Some diagnostic labels e g paronychia warts had been included in the symptom section This was particularly so in the skin chapter where there were insufficient codes available in the diagnostic section In other cases symptoms were included in the diagnostic component eg K85 high blood pressure without a diagnosis of hypertension Further attempts had clearly been made by the Classification Committee to subdivide the diagnostic component in a uniform manner across chapters into infections neoplasms injuries congenital anomalies and other diagnoses However due to the variable extent to which each of these types of problems applied in each body system the range of numerical codes fa
83. nter and health problems requires that the available labels reflect the characteristics of the domain general practice family medicine Labels should be derived from a nomenclature or thesaurus A nomenclature contains all the terms and professional jargon of medicine and a thesaurus is a storehouse of terms like an encyclopedia or computer tape with a large index and synonyms Classification systems provide a structure to order named objects in classes according to established criteria They do not necessarily contain all terms and difficulties arise when they are used as a nomenclature and terms are not found within them Often many terms are included within one rubric so that the use of coding based on a classification does not provide adequate specificity ICPC is a Classification which reflects the characteristic distribution and content of aspects of primary care It is not a nomenclature The richness of medicine at the level of the individual patient needs a nomenclature and thesaurus much more extensive than ICPC particularly for recording the specific detail required in an individual patient record The use of ICPC together with ICD 10 and other Classification systems such as the Anatomical Therapeutic Chemical classification of medications ATC can provide the basis of an adequate nomenclature and thesaurus but if full coding is required these must be supplemented by even more specific coding systems However unless such coding
84. osed symptoms it was still based on the ICD structure and was still inadequate A third edition ICHPPC 2 Defined in 1983 had added to it criteria for the use of most of the rubrics greatly adding to the reliability with which it could be used but not overcoming its deficiencies for primary care A new classification was needed for both the patient s reason for encounter and the provider s record of the patients problems At the 1978 World Health Organisation WHO Conference on Primary Health Care in Alma Ata adequate primary health care was recognised as the key to the goal of health for all by the year 2000 Subsequently both WHO and WONCA recognised that the building of appropriate primary care systems to allow the assessment and implementation of health care priorities was only possible if the right information was available to health care planners This led to the development of new classification systems Return to Instructions ICPC 2 PLus Users Guide Page 28 Return to Instructions Later in 1978 WHO appointed what became the WHO Working Party for Development of an International Classification of Reasons for Encounter in Primary Care This group a majority of whose members were also members of the WONCA Classification Committee developed a Reason for Encounter Classification RFEC 1314715 which later became ICPC Reasons for Encounter Reasons for encounter RFEs are the agreed statement of the reason s why a
85. our medical notes as it reminds you of your thoughts about the symptoms at the previous consultation However a problem list should only contain the diagnosis or problem managed described at the highest level of specificity allowed by the information available For Example The patient presents with symptoms of pallor and shortness of breath After history and examination you feel it is likely to be anaemia and send the patient off for blood tests The recording of the problem should at this stage be both pallor and shortness of breath these are the problems you are investigating Only when the results are returned and your diagnosis of anaemia is confirmed should the problem be recorded in such specific diagnostic terminology linked as earlier suggested If your software allows this does not preclude the additional entry of Anaemia in free text in your notes after that first consultation i e not coded FUTURE PLANS FOR ICPC 2PLUS Continued improvement of keywords and terms to facilitate easy access Extension of the agreement with WONCA to allow the provision of other classifications as they become available Possible additions include Functional Status Charts and the Duke University Severity Index The aim will be to include new tools at no additional costs or at an upgrade cost ICPC 2 has inclusion and exclusion criteria for the majority of problems The possibility of applying these criteria in computer systems in the
86. rding of morbidity Since then there has been increasing recognition of the importance of morbidity studies particularly from general practice to describe and detect changes in the community s health status and to predict health trends that may affect the need for medical services Morbidity data are necessary for the study of causation of disease and factors influencing the incidence and natural history of disease and in the evaluation of the effect of preventive procedures and medical care on the prevalence and severity of disease and the disability resulting from disease The International Classification of Diseases began its career in 1893 as an international list of causes of death Listing for both mortality and morbidity purposes and change of name did not occur until the sixth revision in 1948 The emphasis has therefore been on diseases in terms of their aetiology pathology and morphology Historical Background of ICPC In primary care many of the conditions treated are vague and ill defined and they can be classed only under broad general headings In 1963 the Royal College of General Practitioners estimated that only fifty five per cent of diseases in general practice could be diagnosed accurately in terms of aetiology pathology and morphology Others can only be diagnosed in terms of symptoms or complaints and some consultations such as those for immunisation or medical examination do not relate to an underlying condition Retur
87. re have secondary benefits When collected and aggregated it can be used for clinical health services and health economics research The use of a computer system will improve the quality of patient medical records as they will be always be legible and will usually have greater structure than paper based systems However the collection of information alone is not sufficient to provide meaningful data In order to make information useful to individual practitioners the practice or to epidemiologists it must be easily accessed Why code the data Having decided to introduce computerised medical records into your practice you will be faced with the question of whether or not to code the data Without codes computers will allow you to access information stored in free text by use of word search mechanisms These allow you to sort your patients into groups such as all patients who have the word hypertension in their record However the margin for error is great for you must ask the computer to search for every term you may have used to describe this diagnosis The search will miss words which you have misspelt and you will miss abbreviations now forgotten which you entered in a hurry during a rushed surgery For analysis across the practice you must also be aware of all terms which may have been used by your partner or locum A code is a shorthand for a concept It accurately compresses the data for storage In the computer records environmen
88. rent levels of care to transfer information in a common language It is therefore to your advantage to select a coding system which is internationally recognised mapped to other systems and designed for use in general practice For meaningful data retrieval there is one more facet of computerised medical records which needs to be considered in parallel to the selection of a coding system or systems The medical record must be structured in a manner which allows the computer to recognise the true meaning of the code or term For example the code for Ca breast has a very different meaning in the family history section of the record to its meaning in the patient problem list Any data retrieval requires consideration of the sector of the record in which the term or code is noted The RACGP manual record system has three structural elements based on the work of Lawrence Weed and both can be effectively applied to computerised systems Firstly the problem orientation allows linkage of a problem over time and tracks changing problem definition Secondly the SOAP structure of the data within the encounter subjective data objective data assessment and plan which assures differentiation between lable meanings Thirdly the patient summary which includes an up to date list of all important morbidity and its management Return to Instructions ICPC 2 PLus Users Guide Page 11 Return to Instructions Summary Classification systems ar
89. ry level of organisation of terms on a picklist Site identifies the location of the problem or procedure eg chest arm leg heart etc Selecting a site as a keyword will often produce a long picklist of terms This is useful when identifying terms related to a specific site Acronyms you see in ICPC 2 The following acronyms are generally not used in ICPC 2 terms NOS Not otherwise specified or in clinical terms not yet able to be more specific NEC Not elsewhere classified or in clinical terms not able to be classified more precisely within the options Levels of specificity are usually indicated by the type or site part of the term If this level of specificity is not included then the term is assumed to include the not otherwise specified eg the term hypertension is equivalent to the previously used hypertension NOS Return to Instructions ICPC 2 PLus Users Guide Page 47 Return to Instructions Keywords in ICPC 2 PLUS In addition to the development of a more comprehensive list of Keywords a number of changes have been implemented regarding keywords to provide easier access to terms Following are some hints specifically related to keyword usage Avoid spaces dashes or slashes within Keywords To provide greater uniformity of keyword syntax all spaces dashes and slashes have been deleted No slash S E replaced with SE No dash POST OP replaced with POSTOP CHECK UP replaced with CHEC
90. s Read codes suffer from confusing version terminology A brief history is tabulated below Year Name No of Codes Description 1982 25 brief problem list 1985 4 byte 40 000 GP record summary 1988 5 byte 90 000 Hospital record summary 1994 Version 3 110 000 Full medical record 1995 Version 3 150 000 Full health record The 5 byte set had two versions of data file structure version 1 and 2 Read Version 3 represents a term set code set and file structure Future versions will be labelled by date Advantages Read 5 byte set e t was designed in general practice and therefore includes terms used GPs e t was the first system designed for computers rather than for paper based secondary coding e tis a hierarchical system with five levels each level being more specific e quarterly updates make it dynamic rather than static Return to Instructions ICPC 2 PLus Users Guide Page 16 Return to Instructions Disadvantages The five level structure means you can go down one path looking for the term you want and not realise there is a more appropriate term somewhere else in the hierarchy This can lead to poor inter practitioner reliability in the coding of the same medical concept It is sometimes far too specific For example you can code hit simultaneously by two trains moving in opposite directions There is therefore a high signal to noise ratio which often makes it difficult to locate the term
91. s part of the Demonstration Practice Trials funded by the Commonwealth Department of Human Services and Health However since the trials are finished these practices will now require a license for Read which can be obtained from their UK distributor Computer Aided Medical Services Return to Instructions ICPC 2 PLus Users Guide Page 20 Return to Instructions ICPC is being used by between 20 and 40 practices in Australia usually having been provided with a disk copy of the codes only Without the book which described the philosophy of ICPC the users may have difficulties when needing to choose a code for an unlisted concept Throughout Scandinavia and in parts of North America ICPC is being used in combination with ICD 10 While ICPC is not available in book form at present a disk copy of the book can be obtained from the Family Medicine Research Unit University of Sydney The revised version ICPC 2 will be published in 1997 through Oxford University Press ICPC PLUS is being used by 45 general practices in Australia and one in Fiji the Department of Veterans Affairs for the Health Care Plans and the national hypertension study ANBP2 A feasibility study of its application in Community Health Centres is under way funded by a consortium of NSW SA ACT and QLD State Health Departments It is being considered by the RFDS Aboriginal Health Northern Territory and Victorian Community Health Under Federal Government fundi
92. study carried out in the Netherlands in 1980 The results obtained from this pilot study prompted further feasibility testing in 1983 This was carried out in nine countries namely Australia Brazil Barbados Hungary Malaysia The Netherlands Norway the Phillipines and the United States The entire classification was translated from English into several languages including French Hungarian Norwegian Portuguese and Russian The analysis of more than 90 000 reasons for encounter recorded during over 75 000 individual encounters and the collective experience of the participants resulted in the development of a more comprehensive classification 1218119 Return to Instructions Return to Instructions ICPC 2 PLus Users Guide Page 29 In the course of this feasibility testing it was noted that the RFEC could easily be used to classify simultaneously the reasons for encounter and two other elements of problem oriented care namely the process of care and the health problems diagnosed Thus this conceptual framework allowed the evolution of the Reason for Encounter Classification into the International Classification of Primary Care ICPC Problems in relation to the concurrent development of ICD 10 prevented WHO from publishing the RFEC However WONCA was able to develop ICPC from it and publish the first edition in 1987 While ICPC 1 was much more appropriate for primary care than previous classifications based on the ICD fra
93. systems are based upon a suitable classification such as ICPC is for general family practice it is not possible to extract coherent data about populations rather than just individuals For clinical and medical record purposes a comprehensive nomenclature is needed since the greatest possible level of specificity is required eg lobar pneumonia not just pneumonia or lung disease without grouping even rare conditions together However for statistical purposes this leads to so many categories that the data are unmanageable Grouping of similar rare or less important conditions is essential Return to Instructions ICPC 2 PLus Users Guide Page 26 Return to Instructions Historical background of Classification The statistical study of disease began with work on the London Bills of Mortality in the seventeenth century In the eighteenth and the early nineteenth century there was much interest in the relative incidence of diseases and especially in the change in incidence caused by the disappearance of plague and the control of smallpox Information however was based for the most part on mortality Scanty references to morbidity were derived from general impressions only In the early part of the twentieth century James McKenzie appreciated the importance of morbidity data in his work at St Andrews and in the 1930 s William Pickles reported important epidemiological investigations in country practice with information based on reco
94. t 3 Medication Treatment Procedures Component 4 Test Results Component 5 Administrative Component 6 Referrals amp Other Reason for Encounter Component 7 Diagnosis diseases F70 CONJUNCTIVITIS INFECTIOUS F71 CONJUNCTIVITIS ALLERGIC F72 BLEPHARITIS STYE CHALAZION F73 EYE INFECTIONS INFLAMMATION OTHER F74 NEOPLASM EYE ADNEXA F75 CONTUSION ABRASIONS EYE F76 FOREIGN BODY IN EYE F79 INJURY EYE OTHER F80 BLOCKED LACRIMAL DUCT OF INFANT F81 CONGENITAL ANOMALY EYE OTHER F82 DETACHED RETINA F83 RETINOPATHY F84 MACULAR DEGENERATION F85 CORNEAL ULCER INCL HERPETIC F86 TRACHOMA F91 REFRACTIVE ERROR F92 CATARACT F93 GLAUCOMA F94 BLINDNESS F95 STRABISMUS F99 EYE ADNEXA DISEASE OTHER H EAR Component 1 Complaints amp Symptoms H01 PAIN EAR EARACHE H02 HEARING COMPLAINT H03 TINNITUS RINGING BUZZING EAR H04 EAR DISCHARGE H05 BLEEDING EAR H13 PLUGGED FEELING EAR H15 CONCERN ABOUT APPEARANCE OF EARS H27 FEAR OF EAR DISEASE H28 LIMITED FUNCTION DISABILITY EAR H29 EAR SYMPTOM COMPLAINT OTHER Return to Instructions Return to Instructions Component 2 Diagnostic Screening amp Preventive Procedures ICPC 2 PLus Users Guide Page 61 Component 3 Component 4 Component 5 Component 6 Component 7 Medication Treatment Procedures Test Results Administrative Referrals amp Other Reason for Encounter Diagnosis diseases H70 OTITIS EXTERNA H71 ACUTE OTITIS MEDIA MYRINGITIS H72 SEROUS OTIT
95. t diabetes equates with Type I Others would disagree stating that Type diabetes can also be adult onset In the long term agreement between practitioners both nationally and internationally regarding definitions and synonyms may be reached Until such time creating a hierarchical structure under the upper level of e g diabetes is not possible Return to Instructions ICPC 2 PLus Users Guide Page 40 Return to Instructions Figure 4 2 Diabetic coma Diabetes Mellitus NOS Diabetes complicated Non Insulin dependent diabetes Insulin dependent diabetes Juvenile onset diabetes Adult onset diabetes Possible terms in the Diabetes Mellitus group Diabetes Type I Diabetes Type Il Figure 4 3 CODE A77 Other viral illness Keyword Term Description ICPC Code Term Code VIRAL Adenovirus ATT 001 ADENOVIRUS Adenovirus ATT 001 VIRUS Adenovirus A77 001 COWPOX Cowpox A77 024 DISEASE Coxsackie virus A77 003 COXSACKIE Coxsackie virus A77 003 VIRAL Coxsackie virus ATT 003 VIRUS Coxsackie virus ATT 003 HERPANGINA Coxsackie virus ATT 003 DENGUE Dengue ATT 002 VIRUS Dengue A77 002 VIRAL Dengue A77 002 DISEASE Disease hand foot amp mouth ATT 004 HANDFOOT Disease hand foot amp mouth ATT 004 COXSACKIE Herpangina 77 008 VIRAL Herpangina 77 008 VIRUS Herpangina 77
96. t most agree that it is unsatisfactory to store information only in free text if you wish to retrieve the data and collate it at a later date Return to Instructions ICPC 2 PLus Users Guide Page 6 Return to Instructions At a workshop held by the RACGP during 1993 specific reasons for coding data in medical records were identified They include to provide an audit trail practice audit memory prompts continuity of care assisting other carers in the practice eg partners and locums quality assurance better record keeping decision support and protocols periodic and incidental health checks checking for disease medication interactions dynamic structured patient records cost savings The use of codes does not preclude the use of synonyms acronyms and key words to describe a concept in a medical record but ensures that the concept represented by the code is uniform for all practitioners This results in greater consistency of data input and reliability of reporting Clarity of communication in a common language whether between partners or between primary and secondary care providers will increase quality of care Just as importantly it facilitates accurate and speedy data retrieval If a code has been attached to the label at the time of the encounter a single search for one code will provide a list of all patients with the disease of interest no matter how you described it in the medical record In addition to aiding in
97. ted in ICPC PLUS in a valid ICPC 2 PLUS term Once the conversion from ICPC PLUS to ICPC 2 PLUS was complete the following steps were undertaken as part of the ongoing development of the extended vocabulary A number of new terms were added in response to user requests and the Units own review process e Significant revision of keywords and term access pathways was undertaken e Picklist structure and presentation was targeted for refinement e Tests ordered particularly pathology and imaging were expanded Return to Instructions ICPC 2 PLus Users Guide Page 43 Return to Instructions Analysing stored information with ICPC PLUS Getting the data in to a medical record system in a classified form is of course only the first part of the process There is no point in entering the information if you are unable to draw it out in a useful manner It is important that you utilise the conversion map provided to your software developer to transfer any data collected in ICPC PLUS into ICPC 2 PLUS terms before you begin any data analysis Sorting at ICPC 2 rubric level This is the easiest method of identifying a specific group of patients in your practice You want a list of all your patients who have attended your practice for uncomplicated hypertension Enter hypertensi and you will find the normal picklist associated with that keyword highlight the one you want hypertension uncomplicated and ask the computer to provide the
98. ter RFE diagnoses or problems and process of care Linkage of elements permits categorisation from the beginning of the encounter with RFE to its conclusion Return to Instructions ICPC 2 PLus Users Guide Page 30 Return to Instructions The new classification departed from the traditional International Classification of Disease ICD chapter format where the axes of its several chapters vary from body systems Chapters Ill IV V VI VII VIII IX X XI XIII and XIV to aetiology Chapters l Il XVIL XIX XX and to others Chapters XV XVI XVIIL XXI This mixture of axes creates confusion since diagnostic entities can with equal logic be classified in more than one chapter for example influenza in either the infections chapter or the respiratory chapter or both Instead of conforming to this format the ICPC chapters are all based on body systems following the principle that localization has precedence over aetiology The components that are part of each chapter permit considerable specificity for all three elements of the encounter yet their symmetrical structure and frequently uniform numbering across all chapters facilitate usage even in manual recording systems The rational and comprehensive structure of ICPC is a compelling reason to consider the classification a model for future international classifications Since publication ICPC has gradually received increasing world recognition as an appropriate classific
99. that in order to minimise space and reduce the total number of keywords created shorter keywords are in some instances incorporated into a longer version of the word For example Prostatectomy also incorporates the keyword prostate Rheumatica also incorporates the keyword rheumatic Toxicity also incorporates the keyword oxic Accessory also incorporates the keyword access Sores also incorporates the keyword sore 2 The structure of the ICPC 2 PLUS keyword search allows users to enter as much or little of a keyword as they require when creating a picklist Thus the keyword list that follows is a guide to the ongest version of a word that can be entered as a keyword Shorter versions or the first few letters of the keyword may be entered if required For example Keyword listed Shorter keywords you can enter prostatectomy prostat nerveroot nerv ulnar ulna swallowing swallo glandular glan earache ear Remember entering a shorter keyword will make your picklist of terms longer If you are unable to find the term you require refer to Section 5 Terming with ICPC 2 PLUS for hints on keyword selection or contact the FMRC The Keyword List has been removed from THIS electronic version The Full APPENDIX A is included in the hardcopy version sent to licensed users Return to Instructions ICPC 2 PLus Users Guide Page 73 Appendix B Return to Instructions Keyword Abbreviations APPENDIX B Versio
100. then feel free to record an additional problem called abnormal Pap smear X86 001 or if the Pap smear results were more specific CIN I X86 005 CIN II X86 006 CIN III X86 032 There are a few good examples in ICPC 2 which lend themselves to multiple recording of the same problem in different terms These are usually cases where you have the choice of being more general or more specific An example is where the patient presents after an accident questioning whether his leg is fractured You suspect it is and you send the patient for x ray The problem at this point should be recorded as injury leg L81 As yet you haven t sufficient information to label it as a fracture When the patient returns x rays show a fracture It is the same problem to the patient and therefore should not now be recorded as a new problem of fractured femur L75 It should result in a change of diagnosis from injury L81 to fracture L75 The Code Groupers listed later in this section will give you some idea of the more subtle choices which may present to you in selecting a medical term E g osteoarthritis there is one general OA code but others are more specifically identified by body part Return to Instructions ICPC 2 PLus Users Guide Page 53 Return to Instructions Question What do do when want to write a diagnosis with a question mark e g anaemia Answer This form of provisional diagnosis is often useful in y
101. tion of Primary Care ICPC which incorporated codes for patient reasons for encounter symptoms and ill defined conditions with the addition of the morbidity codes from ICHPPC2 Defined Return to Instructions ICPC 2 PLus Users Guide Page 18 The structure of ICPC differs from that of ICD and Read It has a biaxial structure with 17 chapters on one axis mainly based on body systems with an additional chapter for broad ill defined conditions e g feeling tired general ill feeling etc another for psychological problems and one for social problems On the other axis are 7 components Component 1 covers symptoms and complaints Component 7 covers diagnosis disease and components 2 6 are process codes e g check immunisation test results which apply equally in all chapters It was designed for paper based data collection with the primary care provider selecting the code at the time of the encounter Advantages e lts structure follows the natural process of primary care and facilitates access to meaningful morbidity groups e g all cardiovascular disease all respiratory symptoms all skin infections all injuries all preventive care all immunisations e tis small enough to handle having only 1300 rubrics Disadvantages e Because it was designed as an epidemiological tool it only includes a specific rubric for the most common problems managed in general practice The less common problems are placed into ra
102. to use for primary care purposes and the classifications specially developed for that purpose are to be preferred Return to Instructions ICPC 2 PLus Users Guide Page 32 Return to Instructions References 10 11 12 13 14 15 16 17 18 19 20 21 22 World Health Organisation International Statistical Classification of Diseases and Related Health Problems 10th Revision ICD 10 Geneva WHO 1992 World Health Organisation International Classification of Diseases 9th Revision Geneva WHO 1977 Classification Committee of WONCA ICHPPC 2 Defined International Classification of Health Problems in Primary Care Oxford Oxford University Press 1983 Lamberts H and Wood M eds ICPC International Classification of Primary Care Oxford Oxford University Press 1987 World Organisation of National Colleges Academic amp Academic Associations of General Practitioners Family Physicians The International Classification of Primary Care Oxford University Press 1998 ISBN 0 10 262802 X Hofmans Okkes IM Lamberts H The International Classification of Primary Care ICPC new applications in research and computer based patient records in family practice Family Practice 1996 13 294 302 International classification of diseases 9th revision Geneva World Health Organization 1977 International Statistical Classification of Diseases and Related Health Problems 10th revision Geneva World Health Organisat
103. trical Tracings Other Diagnostic Procedures Preventive Immunisations Medications Observation Health Education Advice Diet Consultation with Primary Care Provider Consultation with Specialist Clarification Discussion of Patient s RFE Demand Other Preventive Procedures High Risk Medication Condition Component 3 MEDICATION TREATMENT THERAPEUTIC PROCEDURES 50 51 52 53 54 55 56 57 58 59 Medication Prescription Request Renewa l Injection Incision Drainage Flushing Aspiration Removal Body Fluid EXCL Catheterisation 53 Excision Removal Tissue Biopsy Destruction Debridement Cauterisation Instrumentation Catheterisation Intubation Dilation Repair Fixation Suture Cast Prosthetic device Apply Remove Local Injection Infiltration Dressing Pressure Compression Tamponade Physical Medicine Rehabilitation Therapeutic Counselling Listening Other Therapeutic Procedures Surgery NEC Return to Instructions ICPC 2 PLus Users Guide Page 57 Return to Instructions Component 4 RESULTS 60 Results Tests Procedures 61 Results Examination Test Record Letter from Other Provider Component 5 ADMINISTRATIVE 62 Administrative Procedure Component 6 REFERRALS AND OTHER REASONS FOR ENCOUNTER 63 Follow up Encounter Unspecified 64 Encounter Problem Initiated by Provider Post op check 65 Encounter Problem Initiated by Other than Patient Provider Anxiety by third person not at encounter 66 Referra
104. ulna However incorporating this level of detail about site or severity throughout ICPC 2 PLUS would result in a large database that no longer has its economies of scale If you want more detail about your diagnosis than is provided by ICPC 2 PLUS your software should allow you to add free text to further describe problems For severity levels we suggest that you speak to your software developer and request the introduction of an additional field for severity which you can use when you wish ICPC 2 PLus Users Guide Page 50 In summary ICPC 2 PLUS will not be expanded to include severity and codes which specify site will remain at the upper level i e ulna rather than be expanded i e to mid shaft versus proximal Question How do know which keyword is best Answer Some keywords such as check disease pain cyst injury are associated with many terms As you get used to the lists provided with these terms you can experiment with other key words which may provide a shorter pick list and so lead you to the desired term with less effort For example for a diagnosis of whiplash if you enter injury as your keyword you will be presented with a long picklist about 81 options A shorter list will present if you enter neck 13 options or whip 2 options If you think that the key word you have entered is appropriate but the pick list is too narrow then consider whether your key word could be made more gen
105. you want In other areas it lacks sufficient specificity for clinical purposes particularly in the psychological and social areas Analysing data using Read can also be difficult because of its size and its ICD structure From a practical viewpoint there are other things about Read that Australian primary care providers should consider The Aus Read Trial demonstrated that many of the Read preferred terms are not suitable in the Australian environment the synonymous terms are more appropriate the hierarchy is not always suitable e g asthma is classified as a specific type of COAD many of the key words i e words that the GP enters in order to find the term they want need to be Australianised Since the trial the Australian Government has not bought a National license for the codes so they will remain fully controlled from the UK Individuals who wish to buy a license for Read Clinical Codes can do so by contacting the distributors direct There will be no Australian back up nor production of an Australian version unless Australia negotiates a licence Those considering buying New Zealand medical record software which uses Read should be aware of this Return to Instructions ICPC 2 PLus Users Guide Page 17 Return to Instructions Read Version 3 is even larger than its predecessor It has been broadened to cover terms used in the entire health record It includes many specialty codes which have

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