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Open Access Highly Accessed Research article

Coding of procedures documented by general practitioners in Swedish primary care-an explorative study using two procedure coding systems

Anna Vikström1*, Maria Hägglund2, Mikael Nyström3, Lars-Erik Strender1, Sabine Koch2, Per Hjerpe4, Ulf Lindblad5 and Gunnar H Nilsson1

Author Affiliations

1 Department of Neurobiology, Care Sciences and Society, Center for Family and Community Medicine, Karolinska Institutet, SE-141 83 Huddinge, Sweden

2 Department of Learning, Informatics, Management and Ethics, Health Informatics Centre-(HIC), Karolinska Institutet SE-171 77 Stockholm, Sweden

3 Department of Biomedical Engineering, Linköpings University, SE-581 85 Linköping, Sweden

4 R&D Centre, Skaraborg PC, Skövde, Sweden 5 Social Epidemiology, Department of Clinical Sciences, Faculty of Medicine, Lund University, Sweden

5 Department of Public Health and Community Medicine/Primary Health Care, the Sahlgrenska Academy at the University of Gothenburg, Sweden

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BMC Family Practice 2012, 13:2  doi:10.1186/1471-2296-13-2

Published: 9 January 2012

Abstract

Background

Procedures documented by general practitioners in primary care have not been studied in relation to procedure coding systems. We aimed to describe procedures documented by Swedish general practitioners in electronic patient records and to compare them to the Swedish Classification of Health Interventions (KVÅ) and SNOMED CT.

Methods

Procedures in 200 record entries were identified, coded, assessed in relation to two procedure coding systems and analysed.

Results

417 procedures found in the 200 electronic patient record entries were coded with 36 different Classification of Health Interventions categories and 148 different SNOMED CT concepts. 22.8% of the procedures could not be coded with any Classification of Health Interventions category and 4.3% could not be coded with any SNOMED CT concept. 206 procedure-concept/category pairs were assessed as a complete match in SNOMED CT compared to 10 in the Classification of Health Interventions.

Conclusions

Procedures documented by general practitioners were present in nearly all electronic patient record entries. Almost all procedures could be coded using SNOMED CT.

Classification of Health Interventions covered the procedures to a lesser extent and with a much lower degree of concordance. SNOMED CT is a more flexible terminology system that can be used for different purposes for procedure coding in primary care.