چشم انداز در عمل: خط‌مشی و رویه‌های کدگذاری بالینی

Introduction: Every health organization life depends on its correct coding system. One of the best tools in collecting correct and valid data is to make a clinical coding and procedures. Clinical Coding policy and procedures, in face of personals changes causes stability, and continues the clinical coding and provide a frame for decision making and doing duties . Methods: This research was carried out as a descriptive-comparative study. Information has taken from books, papers, internet, and health care institutes. The coding policies and procedures from United State, England, Canada, and Iran have been reviewed in this research. Due to similarity or differences in specifications, the suggested paradigm for Iran has been prepared. Then the model has been tested by Delphi method in two phases. And after evaluating it, the final model is presented. Results: Data showed that procedures and coding policies have been presented in main six methods including: documentation and coding principles, coding information validating, coding unit structure, coding training, coding communication, and security and privacy of coding. Fourteen methods related to coding policy are covered by clinical coding unit for these six axis. In each of these axis. Certain procedures have been achieved in each mentioned axis. Documentation principle, coding procedures, time frame coding, summarized coding presentations, documentations and coding error investigations, errors corrections and educational sections, employees job situations and numbers of employee that needed employees evaluations, in-services training, conditions that effected job, and tracking reviewing of recording data systems are some important procedures for these six axis. Conclusions: In total the final model for the clinical coding policies and procedures in Iran have more similarities by United State and England and less by Canada. It have been suggested that coding procedure would be evaluated and upgraded annually and have will be published in special magazine. To evaluate the coding information and coding procedures, an investigation committee have been suggested, in which based on their results, some workshops to be settled. Also for collection information from physicians about important cases, a special questioner form would be designed.