Clinical Data Capture (CDC) - also known as Clinical Coding

Clinical Data Capture is the tool that provides the World Health Organisation with all the information needed for research purposes, health trends and epidemiology. The International Classification of Diseases permits the systematic recording, analysis, interpretation and comparison of mortality and morbidity data, collected in different countries or areas and at different times.

 

The information entered onto the PAS system by Coders is also used by the Department of Health. When questions on health are asked in the Houses of Parliament the reply can be based on information sourced by Clinical Data Capture.

 

Closer to home, the Trust’s business case relies heavily on CDC for many purposes and will underpin Primary Care Group data.

 

Clinical Coders rely totally on the information in patients’ case notes (and Histology and Radiology results) for coding.

 

Although Clinical Coders are not medically qualified they are trained in clinical coding. They are responsible for assigning the consultants/doctors words into code using ICD10* and OPCS4*. It is vital therefore that the information supplied in case notes is clear and concise to enable the staff to code exactly and accurately.

 

Coders are happy to assist clinical staff with any coding query they may have and supply codes for either diagnosis or operations/procedures which are nationally agreed.

 

OPCS4 The Office of Population Censuses and Surveys Classification of Surgical Operations, 4th revision (HMSO)

This is no longer available via the internet, the Clinical Coding department should be contacted for assistance with the coding scheme.

 

ICD10 International Statistical Classification of Diseases and Related Health Problems 10th revision (WHO)  

To contact the Clinical Coding Manager

visit the Clinical Coding intranet web site (coming soon)