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In health care, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification.
The ICD-10 Clinical Modification (ICD-10-CM) is a set of diagnosis codes used in the United States of America. [1] It was developed by a component of the U.S. Department of Health and Human services, [ 2 ] as an adaption of the ICD-10 with authorization from the World Health Organization .
ICD-10 is the 10th revision of the International Classification of Diseases (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. [1]
ICD versions before ICD-9 are not in use anywhere. [16] ICD-9 was published in 1977, and superseded by ICD-10 in 1994. The last version of ICD-10 was published in 2019, and it was replaced by ICD-11 on 1 January 2022. [17] As of February 2022, 35 of the 194 member states have made the transition to the latest version of the ICD. [18]
Informed refusal is where a person has refused a recommended medical treatment based upon an understanding of the facts and implications of not following the treatment. [1] [2] Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also may choose to refuse. [3]
Variations in healthcare provider training & experience [45] [52] and failure to acknowledge the prevalence and seriousness of medical errors also increase the risk. [53] [54] The so-called July effect occurs when new residents arrive at teaching hospitals, causing an increase in medication errors according to a study of data from 1979 to 2006.
Psychoactive substance-induced psychotic disorders outlined within the ICD-10 codes F10.5—F19.5: F10.5 alcohol: [8] [9] [10] Alcohol is a common cause of psychotic disorders or episodes, which may occur through acute intoxication, chronic alcoholism, withdrawal, exacerbation of existing disorders, or acute idiosyncratic reactions. [8]
[1] [2] Documenting patient encounters in the medical record is an integral part of practice workflow starting with appointment scheduling, patient check-in and exam, documentation of notes, check-out, rescheduling, and medical billing. [3] Additionally, it serves as a general cognitive framework for physicians to follow as they assess their ...