Medical Index

Description

Medical Index refers to a set of databases that serve as an index to the patient’s medical record. The index is created by the coding and classification of diagnoses from a patient’s medical record using the patient problem list as the primary source of information. Medical Index is an institutional resource used to identify patients for epidemiological research, statistical analysis, administrative reporting, and quality control.

History

Medical Index conceptualization began with Dr. Henry Plummer. Dr. Plummer devised a system where a patient's records where kept in one file. Dr. Plummer's system ensured that all medical documentation pertaining to a patient could be found in a single dossier. Eventually the need to access groups of dossiers was needed. Dr. Plummer created two simple indexes to allow the retrieval of groups: one index organized by diagnoses and the other by surgical procedure [Kurland, 1981] This was the genesis of what we call Medical Index and Surgical Index today.

The need for accessing patient information continued to grow for patient care, research, and education. Dr. Joseph Berkson was asked to reorganize the filing system. He devised his own coding index, often referred to as Berkson Codes. Dr. Berkson's index made it possible to classify more than 20,000 diseases and sites in the body. Berkson's system worked brilliantly from 1935 to 1974.From 1975 to 1993 coding reorganization was based on the Hospital Adaptation of the International Classification of Diseases, Second Edition (HICDA). Mayo modified this code to increase it's specificity to over 34,000 codes. Additional digits were added to identify individual diseases. Mayo's modified HICDA is still used today with the coding of more than four million entries per year.

In January 1994 Medical Index started to collect original diagnostic text in addition to the coded information. This continued until the start of the new Master Sheet project in November 1996. The Clinical Notes/Dictation system started to collect final diagnosis as part of the patient note. Medical Index began to code the final diagnosis segment of the clinical note.