Training
Category:
Casus:
There are two search-options:
1. Search by typing one (or more) word (fragments) in the search box
Enter one or more word (fragments) in the search box and you will be presented with one or more classes containing these word fragments. Above the list there are 5 tabs that organize the results. The first tab shows the results from all chapters. The second tab Chapter A1 limits the search to the classes from chapter Visits for general examination, routine examination, family planning, prevention, and other reasons for visit. The third tab Sympt.&Dis. shows the results from all chapters with Symptom and Disease components. The fourth tab Interventions shows the results from the Interventions Chapter. The last tab Functioning shows the results that are Functioning and Functioning related.
Within the specified tab you will be presented with a few classes, only relevant to the preselection. You select the class you are looking for and click on Select this code, after which the code will be shown in the answer box on the left side of the screen. You can verify that you have made the correct selection by clicking Show the correct answer. You can then continue by clicking Next.
2. Search by clicking Chapters on the right side of the search box
If you think none of the classes is a good match, and you want to search again click on clear all and you can restart your search by typing other words or by starting the second option for searching within the Chapters. In this search option, to find the proper code, it is advised to have a closer look at the expression. You need to ask yourself if the expression is:
- not related to a health problem, go to Chapter A1
- about a complaint or disease, go to Chapters A – W,
- an intervention, go to chapter I
- related to functioning, go to Chapter II
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Casus
Cases are clinical vignettes and can be used to assess your knowledge of the ICPC-3. It is recommended that you first read the document with the basic concepts. It explains the meaning of e.g. reason for encounter, functioning and functioning related and episode of care.
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Abnormal finding
Abnormal findings can sometimes be used as a Reason for Encounter but also as an Episode of Care. Normal clinical findings are not to be classified with ICPC-3. Examples of classes with an Abnormal finding label: AS50 Other specified abnormal result investigation. BS50 Splenomegaly. BS51 Unexplained changes in white blood cells. BS52 Elevated erythrocyte sedimentation rate. DS50 Hepatomegaly. The classes for abnormal findings are in the component S Symptoms, complaints and abnormal findings. In each chapter, the abnormal findings classes start with the rank number 50.
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Chapter A1
Chapter general, routine examination, family planning, prevention, and other reasons for visit. Sometimes there is no apparent health problem involved in an episode of care, e.g. when it relates to need for immunization or a screening, family planning, patient preferences or case finding. These contacts can also be related to first contact or certification. Interventions and Processes carried out in these episodes of care are to be coded with the Interventions and ProcessesCodes in Chapter I. With the classes in this chapter, it is possible to systematically record what a person can or cannot do in the context of health.
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Diagnosis
In general practice three diagnostic categories are used: 1. Symptoms and Complaints diagnoses using a symptom or complaint as the best medical label for the episode. 2. Nosological diagnoses (Syn. syndrome) using a symptoms and complaints complex based on consensus among physicians, but which lacks a proven pathological or pathophysiological basis or aetiology. 3. Pathological/pathophysiological diagnoses having a proven pathological/pathophysiological substrate and/or proven aetiology. In this training we ask you to code the diagnoses from component D and sometimes from component S of chapters A to W. In the component D of the chapters A - W the classes are in the same order, with the same code-range and with corresponding colouring: 1-24 Infections, 25-34 Neoplasmata, 35-54 Traumata, 55-64 Congenital, 56-98 Other diagnosis (syndromes etc.), 99 Other specified and unknown diseases, problems.
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Functioning and Functioning related
This chapter allows a description of the functioning and functioning related aspects of all persons (first and follow-up) contacts with the health care system in primary- and community care settings.
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Interventions and Processes
With the classes from the Chapter Interventions and Processes, examinations and policy can be systematically coded. The interventions are always linked to a care episode. The choice of the letter for the 3 numbers, e.g. -105 blood test, of the intervention code is determined by the chapter choice of the care episode. As an example, requesting a blood test for an intestinal disorder is coded with D105.
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Problem
With the classes in this Chapter, social problems influencing health status can be coded. A social problem is an issue within the personal environment or society that makes it difficult for people to achieve their full potential. Poverty, unemployment, unequal opportunity, racism, and malnutrition are examples of social problems. So are substandard housing, employment discrimination, and child abuse and neglect.
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Symptoms and Complaints
A symptom is any expression of disturbed function or structure of the body and mind by a patient. Cough, pain, and tiredness e.g. are symptoms. In the component S of the chapters A - W the classes are in the same order, with the same code-range and with corresponding colouring: 01-49 Symptoms and complaints, 50-89 Clinical findings. A part of the clinical findings are now the abnormal test results, 90-98 Concern, fear of disease and 99 Other specified symptoms, complaints and abnormal clinical findings.
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