CODING WITH THE INTERNATIONAL CLASSIFICATION OF PRIMARY CARE BY FAMILY  MEDICINE RESIDENTS

Daniel Pinto & Susana Corte-Real

Objectives: To determine the ability of Portuguese doctors in the second 
half of their family medicine residency to code with the International 
Classification of Primary Care – revised version (ICPC-2).
Study design: Cross-sectional.
Setting: South of mainland Portugal, Azores e Madeira.
Participants: Residents in the 29th and 30th courses of the Family 
Medicine Residency Coordination of South Portugal.
Methods:A convenience sample of 100 residents was contacted by email, 
and asked to code three clinical vignettes written by the authors. The 
correct coding of reasons for encounter, diagnoses, and processes was 
determined by the authors with the help of a national ICPC-2 expert. We 
made a descriptive analysis of the proportion of correct answers, 
failures of classification, and most frequent errors. The answers of 
residents with and without previous training in ICPC-2 usage were compared.
Results: The participation rate was 47.0%. 56.5% of reasons for 
encounter, 75.9% of diagnoses, and 48.8% of processes were correctly 
classified. Residents frequently coded in excess parts of the visit that 
are not, by the ICPC-2 definition, reasons for encounter; they 
frequently left out the code “health maintenance/preventive medicine” 
from problems and reasons for encounter; and, in processes, they seldom 
code the complete and partial medical examination. Residents who had 
previous training in ICPC-2 usage correctly coded more reasons for 
encounter (72.3% vs 55.1%) and problems (85.0% vs 74.8%).
Conclusion: Residents appear to be better at coding diagnosis than 
reasons for encounter or processes. Errors in the coding of preventive 
activities and medical examination are frequent. Residents who had 
training in ICPC-2 usage had better results in coding of reasons for 
encounter and problems.
Keywords: Classification; Family Practice; Residency.

Pinto, D., & Corte-Real, S. (2010). Codificação com a Classificação Internacional de Cuidados Primários (ICPC) por internos de Medicina Geral e Familiar. Rev Port Clin Geral, 26, 370–382. Retrieved from http://www.ph3c.org/PH3C/docs/27/000270/0000336.pdf