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A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system.
The AAPC, previously known by the full title of the American Academy of Professional Coders, [4] is a professional association for people working in specific areas of administration within healthcare businesses in the United States. [5]
(April 2013) (Learn how and when to remove this message) DOCLE ( Do ctor C ommand L anguag e ), [ 1 ] [ 2 ] is a non-numeric health coding and medical classification system. The DOCLE system is used [ 3 ] in Health Communication Network's electronic medical record and patient management software package, Medical Director.
ICD has a hierarchical structure, and coding in this context, is the term applied when representations are assigned to the words they represent. [30] Coding diagnoses and procedures is the assignment of codes from a code set that follows the rules of the underlying classification or other coding guidelines.
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. [1]
Reproducible: A coder would need to make sure that the record is reproducible in that copies can be made to aid in effective coding. [8] Clinical coder experience. The experience of the health professional coding a medical record is an essential variable that must be accounted for when analysing the accuracy of coding.
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