Classification system
The main aims of clinical documentation from the viewpoint of the therapist are support of patient care, therapy control, quality management, decision support, research and professional education and training.
From the viewpoint of the economist clinical documentation has to support health care administration and reimbursement, health and accident insurance. For that standardized recording of medical performance and health data is required in order to evaluate costs and to guarantee balanced prices.
The following information are important for clinical documentation and health care administration:
- The hypothetical diagnosis after admission of a patient to hospital
- All diagnostic and therapeutic procedures carried out during stay in hospital
- all diagnoses related with patient's history and findings during stay in hospital
- discharge diagnosis which is the main cause for hospital treatment and possibly some more secondary diagnoses
These information play an important role in reimbursement systems worldwide. The central problem of health care data analysis is the transformation of patient data in a standardized form suitable for electronic data processing. This task can not be done using a standard nomenclature or terminology, but only by a complete classification system. The worldwide best known classification systems for diagnoses and procedures are provided by the WHO.