A computerized and legal medical record, created in medical settings like hospitals and surgery rooms, is an electronic medical record. Electronic medical records allow retrieval of records, storage and analysis of records. Professional Dynamic Network maintains an off-site, remote medical coding facilities. Contact PDN for medical coding services.
Clinical or Diagnostic Coder
A medical record coder who specializes in such a medical records keeping is known as a Clinical Coder or a Diagnostic Coder. Health care professionals, or medical coders, who analyze clinical statements and allocate codes from a clinical classification, are essential for records keeping. The data, generated by maintaining accurate records, may be used for clinical research, health resource allocation, epidemiology and public education and is an integral part of modern medical informatics.
With several clinical classifications that used throughout the world, medical coders have different methodologies or groups of data analysis tools to use. An example is the classification designated to classify a disability, it is different from the one designed to classify inpatient morbidity. Therefore, it is very important for the medical coder to have a broad understanding of both the clinical classifications and clinical documentation requirements. For the educational growth of medical coders, it is necessary to have both the summative and formative training alongside experience.
The Job of a Healthcare Medical Coder or Transcriptionist
Now the question arises: what is the job of a medical coder? A medical coder classifies the medical concepts using the common and standardized classification. Basically, the task of a medical coder is classified into three different key phases of clinical coding.
- Abstraction – this involves reading the entire record of a patient’s health problem and then analyzing the root causes and the treatment that cured him. Medical coders receive this information through a variety of sources like laboratory, radiology results, clinical notes and operation notes.
- Assignment – finding the appropriate code from the abstraction part and entering it into the system used for collecting the coded data is a part of this activity.
- Review – it is very important for a medical coder to review the coded set of data generated from the assignment phase. By this, the clinical coders can check and confirm that they have covered everything that is required and that there are no extraneous codes.
Coding or Transcriptionist Accuracy
The skills required by a medical coder require accuracy. Coders must have a working knowledge of medical sciences and terminology; he has to have the ability to read handwritten materials and be capable of making decisions about the use of appropriate codes assigned by the clinical documentation. It is also very important for a medical coder to understand the use of statistical classification and its structure.
Medical coders specialize in orthopaedics, nephrology, gastroenterology, neurology and cardiology based upon authority and job assignments in particular hospitals.
Based on competency level, medical coders are classified into the following categories:
- Entry-level coder – introductory trainer
- Intermediate level coder – codes many cases independently, frequently with incomplete information
- Advanced level coder – code all cases, easy and complex
- Nosologist – expert in more than one classification