Role of International Classification of Diseases in medical record management.

Abstract

The Medical Record is the major source of Health information. Therefore, it is necessary to maintain good patient records by documenting all the required information, e.g. history, physical examination, progress notes, investigations, treatment including surgical procedures, complete diagnosis and end result, etc., as per the guidelines stated in the International Classification of Diseases published by World Health Organisation. If the documentation is accurate and complete, the health care information could be obtained and classified accurately and completely according to International Classification of Diseases published by WHO. Hence, International Classification of Diseases plays an important role in managing good medical records.