The proportion of inadequately ICPC2 signs and symptoms coded as a chronic disease in general practice/family medicine: a preliminary study in Central Portugal
DOI:
https://doi.org/10.32385/rpmgf.v39i2.13471Keywords:
General practice, Classifications, Medical recordsAbstract
Objective: To identify ICPC-2 chapters “signs and symptoms” incorrectly classified as active and chronic ones, its proportion and main involved chapters.
Methods: An observational, cross-sectional, quasi-random, exploratory study was carried out using data collected from consultations every Tuesday, Wednesday, and Friday during August of 2021, in the consultations of two General Practice/Family Doctors in Primary Care Health Unit of the Portuguese National Health Service. A descriptive analysis of the list of active problems of the users and recording of the classifications considered inappropriate was performed.
Results: The evaluated population consisted of 123 patients, 52,8% female, mean sample age being of 53,3±22,4 years. For 45,5% of the patients there were chronic misclassifications, with 8,2% misclassifications. The musculoskeletal (16,3%), psychological (7,3%) and the female genital, circulatory and general and nonspecific (all with 5,7%) chapters were the most frequent. There were no significant difference by gender and age, but the greater the number of total classifications, the greater the number of misplaced classifications.
Discussion: The results may have a negative impact on patient follow-up, communication between physicians and increased time spent in consultations, due to the lack of updating the list of problems, and decreased credibility of records for investigation. The high prevalence of musculoskeletal signs and symptoms can lead to the resolution of these problems as chronic. The COVID-19 pandemic can be associated with a greater number of transient symptoms but classified as active. A large number of active issues can affect appropriate classification.
Conclusion: It is important to periodically update the list of problems, invest in the training of family doctors in ICPC-2 use and frequently evaluate the classifications. Further validation studies of classified information in electronic record systems are needed.
Downloads
References
Pinto D. O que classificar nos registos clínicos com a Classificação Internacional de Cuidados Primários? [What should we code in health records with the International Classification of Primary Care?]. Rev Port Med Geral Fam. 2014;30(5):328-34. Portuguese
Organização Mundial de Médicos de Família (WONCA). Classificação internacional de cuidados de saúde primários [Internet]. 2ª ed. Lisboa: Administração Central do Sistema de Saúde; Associação Portuguesa dos Médicos de Clínica Geral; 2011. Available from: https://www.mgfamiliar.net/wp-content/uploads/apmcg_ICPC-v-1.7.pdf
Santiago LM, Carvalho R, Botas P, Miranda P, Matias C, Simões AR, et al. A informação na consulta presencial em medicina geral e familiar: classificações segundo a ICPC-2 e anotações livres para a memória futura no SOAP [Information available in general practice/family medicine consultations: coding and annotations for future use]. Rev Bras Med Fam Comun. 2015;10(36):1-8. Portuguese
Tato R. ICPC-2: Sistema auxiliar de classificação. Rev Port Clin Geral. 2009;25(1):83.
Heleno LV. A propósito do artigo “O que classificar nos registos clínicos com a classificação internacional de cuidados primários?” [Regarding: “What should we code in health records with the International Classification of Primary Care?”]. Rev Port Med Geral Fam. 2015;31(1):53-4. Portuguese
World Organization of Family Doctors. International classification of primary care [Internet]. Brussels: WONCA; 2016. Available from: https://www.globalfamilydoctor.com/site/DefaultSite/filesystem/documents/Groups/WICC/International%20Classification%20of%20Primary%20Care%20Dec16.pdf
Gissler M. How to maintain good quality register systems? Acta Med Port. 2019;32(5):335-7.
Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93(3):380-3.
Granja M, Outeirinho C. Registo médico orientado por problemas em medicina geral e familiar: atualização necessária [Problem-oriented medical record in family practice: a necessary update]. Rev Port Med Geral Fam. 2018;34(1):40-4. Portuguese
Queiroz MJ. SOAP revisitado [SOAP revisited]. Rev Port Clin Geral. 2009;25(2):221-7. Portuguese
Barreiro D, Santiago LM. Motivos de consulta em medicina geral e familiar no distrito de Coimbra no ano de 2010 [Reasons for clinical encounter in General Practice/Family Medicine in 2010 in Central Portugal]. Rev Port Med Geral Fam. 2013;29(4):236-43. Portuguese
Basílio N, Ramos C, Figueira S, Pinto D. Worldwide usage of International Classification of Primary Care. Rev Bras Med Fam Comun. 2016;11(38):1-9.
Botsis T, Bassøe CF, Hartvigsen G. Sixteen years of ICPC use in Norwegian primary care: looking through the facts. BMC Med Inform Decis Mak. 2010;10:11.
Kæmpe KR, Mortensen OS. The distribution of diagnoses in a population of individuals on long-term sick leave. Dan Med J. 2021;68(2):A06200429.
Frese T, Herrmann K, Bungert-Kahl P, Sandholzer H. Inter-rater reliability of the ICPC-2 in a German general practice setting. Swiss Med Wkly. 2012;142:w13621.
Vais CI. Método SOAP em MGF: o que deverá ser colocado em S ou em P [dissertation]. Covilhã: Universidade da Beira Interior; 2016.
Santiago LM, Miranda PR, Botas P. Tendência de classificação no capítulo Z da CIAP-2 entre 2006 e 2011 em um centro de saúde de medicina familiar em Coimbra, Portugal [Classification trends with the ICPC-2 Z chapter from 2006 to 2011 in a family medicine health centre in Coimbra, Portugal]. Rev Bras Med Fam Comun. 2013;8(27):106-11. Portuguese
Gusso G. The International Classification of Primary Care: capturing and sorting clinical information. Cien Saude Colet. 2020;25(4):1241-50.
Maurício B, Rocha F. Revisitando registos clínicos em MGF: um instrumento de apoio à prática clínica [Internet]. Moscavide: USF Tejo; s.d. [cited 2021 Oct 11]. Available from: https://www.mgfamiliar.net/wp-content/uploads/FerramentadeapoioRegistosClinicos-2.pdf
Granja M. Os registos dos médicos de família estão em perigo [Family practice records are in danger]. Rev Port Med Geral Fam. 2018;34(1):33-9. Portuguese
Melo M. O uso da ICP nos registos clínicos em medicina geral e familiar [The use of ICPC in clinical records in general practice]. Rev Port Med Geral Fam. 2012;28(4):245-6. Portuguese
Braga R. Os registos clínicos e a classificação [Clinical records and coding]. Rev Port Med Geral Fam. 2012;28(3):155-6. Portuguese
Letrilliart L, Gelas-Dore B, Ortolan B, Colin C. Prometheus: the implementation of clinical coding schemes in French routine general practice. Inform Prim Care. 2006;14(3):157-65.
Prazeres F, Santiago L. Relationship between health-related quality of life, perceived family support and unmet health needs in adult patients with multimorbidity attending primary care in Portugal: a multicentre cross-sectional study. Health Qual Life Outcomes. 2016;14(1):156.
Prazeres F, Santiago L. The knowledge, awareness, and practices of Portuguese general practitioners regarding multimorbidity and its management: qualitative perspectives from open-ended questions. Int J Environ Res Public Health. 2016;13(11):1097.
Magalhães AR, Penetra J, Pereira C, Carvalho R, Neto MG, Santiago LM. Caracterização do perfil dos grandes utilizadores de uma Unidade de Saúde Familiar [Profile of the frequent attenders at a family health unit]. Rev ADSO. 2016;4(6):15-21. Portuguese
Coelho CC. Motivos de consulta em medicina geral e familiar: tendência evolutiva na última década na região Centro de Portugal [dissertation]. Coimbra: Faculdade de Medicina da Universidade de Coimbra; 2021.
Pinto D, Corte-Real S. Codificação com a classificação internacional de cuidados primários (ICPC) por internos de medicina geral e familiar [International classification for primary care (ICPC) coding by family medicine trainees]. Rev Port Clin Geral. 2010;26(4):370-82. Portuguese
Downloads
Published
Issue
Section
License
Copyright (c) 2023 Portuguese Journal of Family Medicine and General Practice
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The authors will assign to the RPMGF the sole right to publish and distribute the content of the manuscript specified in this declaration via physical, electronic, broadcasting or any other medium that may come into existence. They also grant the RPMGF the right to use and exploit this manuscript, in particular by assigning, selling or licensing its content. This permission is permanent and takes effect from the moment the manuscript is submitted, has the maximum duration allowed by applicable Portuguese or international law and is of worldwide scope. The authors further declare that this assignment is made free of charge. If the RPMGF informs the authors that it is not going to publish their manuscript, the exclusive assignment of rights ceases forthwith.
The authors authorise the RPMGF (or any entity it may appoint) to act on their behalf when it believes that copyright may have been infringed.
