Miscellaneous Section Flashcards
Define what Hospital Episode Statistics (HES) is.
A data warehouse containing details of all admissions, outpatient
appointments and A and E attendances at NHS hospitals in England.
The lack of information, or presence of discrepancies, in the medical record
should be addressed through what two local governance mechanisms?
Information governance
Clinical governance
List the three types of Standard found in the ICD-10 and OPCS-4 National
Clinical Coding Standards reference books.
General coding standards
Chapter standards
Coding standards
The ICD-10 and OPCS-4 National Clinical Coding Standards reference books
contain Coding Standards, which must be applied in the manner described;
what does the compliance with this enable?
Compliance with a coding standard enables consistent, accurate and uniform
coding which in turn supports the collection and comparison of local and
national data across time.
How do Coding Standards appear in the ICD-10 and OPCS-4 National
Clinical Coding Standards reference books?
Each standard is contained within a grey box
What is a ‘health record’ defined as in the National Clinical Coding Standards
ICD-10 & OPCS-4 (2019) reference books?
A record consisting of information about the physical or mental health or
condition of an individual made by or on behalf of a health professional in
connection with the care of that individual.
According to the ICD-10 and OPCS-4 National Clinical Coding Standards
reference books, a number of documents are typically included in a health
record; list six of these.
Handwritten notes Computerised records Correspondence between health professionals Discharge letters Clinical work-sheets Discharge forms Nursing care pathways Diagnostic test reports
List the three types of Standard found in the ICD-10 and OPCS-4 National
Clinical Coding Standards reference books
General coding standards
Chapter standards
Coding standards
The ICD-10 and OPCS-4 National Clinical Coding Standards reference books
contain Coding Standards, which must be applied in the manner described;
what does the compliance with this enable?
Compliance with a coding standard enables consistent, accurate and uniform
coding which in turn supports the collection and comparison of local and
national data across time.
How do Coding Standards appear in the ICD-10 and OPCS-4 National
Clinical Coding Standards reference books?
Each standard is contained within a grey box.
What is a ‘health record’ defined as in the National Clinical Coding Standards
ICD-10 & OPCS-4 (2019) reference books?
A record consisting of information about the physical or mental health or
condition of an individual made by or on behalf of a health professional in
connection with the care of that individual.
