Database Abstracting

The coding professional reviews the health record and enters specific data into a computer database (Sayles). Abstracting is a clinical coding function that involves extracting data from the health record and entering information in an index. Index is a guide that serves as a pointer or indicator to locate something (Sayles). There are different types of indexes in healthcare such as disease, operation, and physician. A disease index consist of a list of diagnosis codes arranged by the code number of the patients discharged from the facility. Each patient’s diagnoses are converted from a verbal description to numerical code (Sayles). The patient’s diagnosis codes are entered into the facility’s health information system as part of the discharge processing of the patient’s health record (Sayles). The records can be retrieved by diagnosis, because the index always includes the patient’s health record number as well as the diagnosis codes. Each patient has a health record number, which is linked back to the patient’s name. This makes the disease index considered a patient-identifiable database. The disease index also may include information such as the attending physician’s name and the data of discharge (Sayles). When abstracting occur for any reason, the patient information will be de-identified from index. American Health Information Management …show more content…
The minimal amount of data required for disease or operation index usually includes: associated procedures, attending physician’s code or name, the hospital service, the end result of hospitalization, dates of encounter, patient’s gender, age, and race, patient’s health record number, the principal diagnosis and relevant secondary diagnoses (Sayles). AHIMA recommends a ten year retention period for the operation