Health Records & Clinical Coding

Health Records & Clinical Coding

Health records play an important role in modern healthcare. They have two main functions, which are described as either primary or secondary.

The primary function of healthcare records is to record important clinical information as part of the care provided to patients.

Health records can also be used for secondary purposes:

  • to improve public health and the services provided by the NHS, such as treatments for cancer or diabetes;
  • to determine how well a particular hospital or specialist unit is performing,
  • to track the spread of, or risk factors for, a particular disease (epidemiology), and
  • in clinical research, to determine whether certain treatments are more effective than others.

Clinical coding is the process whereby information written in the patient notes is translated into coded data and entered into hospital information systems. Coding usually occurs after the patient has been discharged from hospital, and must be completed to strict deadlines so that hospitals can be reimbursed for their activity.

Resources

nhs choices logo

The NHS Choices website provides a good overview of health records and their role in modern healthcare.

HSCIClogo

For England, the HSCIC provides a range of tools and guidance about Clinical Records Standards and Summary Care Records (SCR).

The NHS Classification Service is the definitive source of clinical coding guidance and sets the national standards used by the NHS in coding clinical data.

The Clinical Coding Toolbox contains a range of tools and resources to support your coding knowledge and professional development.

ihrim logo

The Institute for Health Record and Information Management (IHRIM) is the Awarding Body for the National Clinical Coding Qualification (UK), the only nationally recognised qualification for clinical coders working in the NHS.

prsb logo

The Professional Records Standards Body provides overall professional governance of the structure and content standards for health and social care records, including their maintenance, and professional assurance of standards proposed for implementation in care records and communications. It is a first point of contact for all matters relating to professional record standards.