This article explains the clinical coding systems used to record information about diagnoses in the database.
Medical Vocabularies include SNOMED-CT, DOCLE, PYEFINCH AND ICPC2+. Nationally recognised disease classification and terminology systems include OCPC2, ICD1-AM and SNOMED-CT.
SNOMED-CT has been identified by the Australian Digital Health Agency (ADHA) as the preferred clinical terminology. For more information on ADHA's supported clinical terminology, review the ADHA website.
Bp Premier uses a combination of SNOMED-CT and PYEFINCH coding. If diagnoses are recorded using the supplied Diagnosis drop-down lists in Bp Premier's clinical record, they will be coded according to these standards.
PIP requirements, data extraction and reporting
The use of these coding systems within Bp Premier complies with PIP Requirement 3 Data Records and Clinical Coding. Data extraction tools for PIP or other reporting purposes will extract diagnoses selected from the dropdown list as SNOMED-CT and PYEFINCH coding.
However, free text diagnoses are not coded (that is, diagnoses typed into the free text field). You can clean up uncoded past history items by using a utility that maps free text diagnoses to Bp Premier's coding. See Cleaning up uncoded and free text data for more information.
Note that if you tick the Reason for prescription and Reason for visit checkboxes, you must have selected from a Diagnosis drop-down and not free text for these 'time saver' reasons to be coded properly, and not recorded as free text.