Primary care health professionals’ approach to clinical coding (V1.0)
Research type
Research Study
Full title
Primary care health professionals’ approach to clinical coding: a qualitative study
IRAS ID
316115
Contact name
Aled Huw Davies
Contact email
Sponsor organisation
Cwm Taf Morgannwg UHB
Duration of Study in the UK
1 years, 0 months, 1 days
Research summary
Clinical coding in primary care using Read and SNOMED-CT codes forms an essential part of every patient’s electronic health record (EHR). The process of creating an entry in a patient’s EHR to document any form of encounter starts with selecting the appropriate clinical code. This is done by searching a keyword or phrase in the clinical code section of the EHR, which then brings up a list of possible relevant clinical codes to be selected. Use of relevant and accurate clinical codes can improve patient care (e.g. by keeping disease registers up-to-date and flagging those who need chronic disease reviews), give insights into population health, and is essential in research. How clinical and non-clinical staff use clinical codes in primary care is poorly understood and researched. Guidance on the subject is limited and out of date.
We aim to understand how clinical and non-clinical staff use clinical coding in their daily work through a qualitative study using semi-structured interviews. We hope to identify the facilitators and barriers for using appropriate and relevant codes in a patient’s EHR, what training they might have had in using clinical coding, the relevance of clinical coding to them, and find and share examples of ‘good practice’.
REC name
N/A
REC reference
N/A