Clinical coding is a computer-based process that transforms narrative clinical text into information that health care stakeholders can use for research, clinical care and other purposes. Clinical coding converts natural language descriptions written by clinicians into statistical code that supports clinical uses and statistical processes, according to the National Center for Biotechnology Information.
Clinical coding structures the data entered in clinical records to improve health care reporting, diagnoses and the general quality of care, claims the National Center for Biotechnology Information. The structured text may include codes from standard medical terminologies to ease clinical reporting. Typically, clinical coding makes use of software applications that provide edits and tips and facilitate alphabetic searches. Although physicians may conduct coding assignments, other personnel, such as professional coders, usually perform these tasks.
Clinical coding attempts to solve the problems posed by manual chart reviews, which are time-consuming and prone to human error. Researchers can use clinical coding to identify subjects for controlled trials or analyze quality measures during a disease outbreak. Clinical coding is also important in clinical decision support and in the application of clinical guidelines. Although there are varying degrees of complexity in coding and classification, basic clinical coding programs assign classes and codes to unstructured data, states the National Center for Biotechnology Information.