Coding clinical records

In the early days of medical computing it was quite common to see the computer as a way of storing medical records as ‘free-text’. That is, clinicians could enter whatever they wanted to record, just as they could with hand-written notes. Nowadays it is generally accepted that the advantages of ‘coded’ clinical data outweigh the possible disadvantages.

In those early days coded data meant just that; the user would be expected to enter a code, such as ‘A123’, which would represent a medical term. Now, medical data can be encoded ‘behind the scenes’ without the clinicians needing to be aware of the coding process.

The benefits of encoding clinical data are:

1. It can be much faster than typing in free-text (especially for clinicians, who are not renowned for their typing skills).

2. Once entered, the data are readily searchable and retrievable because of their inherent structure.

3. Also because of the structure of a coding system, it becomes much more feasible to analyse and audit clinical data.

Clinicians have seen the disadvantage of a coding system as being excessive structuring of information – a restriction on what they are able to record about a patient. Whereas it should be recognised that data recording will be constrained, this can also be a powerful advantage.