Classification trends with the ICPC-2 Z Chapter from 2006 to 2011 in a Family Medicine Health Centre in Coimbra, Portugal
DOI:
https://doi.org/10.5712/rbmfc8(27)639Keywords:
Primary Health Care, Family Practice, Classification, Episode of Care, Social Inequity, International Classification of Diseases, ICPC, International Classification of Primary CareAbstract
Objective: To study the classification trend in ICPC-2, Z Chapter, in the period 2006-2011, in terms of frequency in variation of the total number of sign and symptom components; volume of “population-adjusted classification”; and - based on SOAP for collecting information - which of its components were more frequently recorded in the Subjective (S) and Assessment (A) fields. Methods: Cross-sectional, observational, descriptive study of electronic registries in the SAM (Serviço de Apoio ao Médico - medical visit assistant software) using data collection tool (SAM-Statistics) in August 2012 in Coimbra, central Portugal. Classification volume was studied using codes/1000 inhab/day. The population for each year was calculated based on the middle of each study period. The six most frequent codes in each year were selected. Results: A positive increasing trend was found between 2006 and 2011 in the Subjective and Assessment recording fields, in terms of the total of codes (S:+4,83; A:+6,44) and classification volume - codes/1000 inhab/day (S:+4,40; A:+6,44), as well as in the percentage of different components of the Z sign and symptom codes (S: +0,30; A: +0,56). Conclusions: From 2006 to 2011, a positive trend was found in the ICPC-2 Z Chapter classification, which was more important in Assessment (A), and the type of components recorded through the SOAP method. Hence, continuing medical education is still necessary to improve performance in the crucial task of classification, registering and clinical noting to avoid lack of clinical information.
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European Academy of Teachers in General Practice. The European Definition Of General Practice / Family Medicine. Short Version Euract; 2005. [online] [acesso em 2012 Ago 25]. Disponível em: http://www.euract.eu/official-documents/finish/3-official-documents/95-european-definition-of-general-practicefamily-medicine-2005-short-version.
Sousa JC. Ups! Será que é MUPS? Rev Port Clin Geral. 2006; 22: 277-9.
Royal College of General Practitioners - RCGP. [online] [acesso em 2012 Ago 23]. Disponível em: http://www.rcgp.org.uk/PDF/MUS_Guidance_A4_4pp_6.pdf.
World Health Organization - WHO. Classifications of Diseases. [online] [acesso em 2012 Ago 25]. Disponível em: http://www.who.int/classifications/icd/adaptations/CIAP2/en/index.html.
5.National Institute for Public Health and the Environment – RIVM. Manual for the Use of the ICPC2-ICD10 Thesaurus. [online] [acesso em 2012 Ago 25]. Disponível em: http://www.rivm.nl/whofic/cdromthesaurus/Manual%20Thesaurus%20bilingual_files/frame.htm.
Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14; 278(11): 593-600. http://dx.doi.org/10.1056/NEJM196803142781105
Weed LL Medical records that guide and teach N Engl J Med. 1968 Mar 21; 278(12): 652-7 concl.
Botica MV, Zele I, Renar IP, Markovi? BB, Grgurevi? SS, Botica I. Structure of visits persons with diabetes in Croatian family practice: analysis of reasons for encounter and treatment procedures using the CIAP-2. Coll Antropol. 2006 Sep; 30(3): 495-9.
Witry MJ, Doucette WR, Daly JM, Levy BT, Chrischilles EA. Family physician perceptions of personal health records. Perspect Health Inf Manag. 2010 Jan 1; 7: 1d.
Administração Central do Sistema de Saúde - ACSS. Sistema de Apoio ao Médico - SAM. [online]. Disponível em: http://dis.dgs.pt/2010/10/01/sistema-de-apoio-ao-medico-sam/.
Rodrigues JG. Why do patients consult their Family doctor? Rev Port Clin Geral 2000; 16: 442-52.
Ordem dos Médicos. Código Deontológico. [online] [acesso em 2012 Ago 25]. Disponível em: https://www.ordemdosmedicos.pt/?lop=conteudo&op=9c838d2e45b2ad1094d42f4ef36764f6.
Portugal. Comissão Nacional de Protecção de Dados. Lei nº 12/2005, de 26 de janeiro de 2005. Informação genética pessoal e informação de saúde. Diário da República de Portugal, Lisboa, 26 jan. 2005. Série 1, n. 18. [online] [acesso em 2012 Ago 25]. Disponível em: http://www.cnpd.pt/bin/legis/nacional/Lei12-2005.pdf.
Braga R. Os registos clínicos e a classificação. Rev Port Med Geral Fam. 2012; 28: 155-6.
Lopes JMC. Consulta e abordagem centrada na pessoa. In: Lopes JMC, Gusso GDF, editores. Tratado de Medicina de Família e Comunidade. São Paulo: Artmed; 2012. p. 112-123.
Borrel Carrió F, Dohms M. Relação clínica na prática do médico de família. In: Lopes JMC, Gusso GDF, editores. Tratado de Medicina de Família e Comunidade. São Paulo: Artmed, 2012. p. 124-134.
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