Requirement 3 - Data Records and Clinical Coding

There are no software conformance requirements for this Requirement.

Practices must ensure that where clinically relevant, they are working towards recording the majority of diagnoses for active patients electronically, using a medical vocabulary that can be mapped against a nationally recognised disease classification or terminology system. Practices must provide a written policy to this effect to all GPs within the practice. An active patient is a patient who has attended the practice three or more times in the past two years.

Medical Vocabularies include SNOMED-CT, DOCLE, PYEFINCH and ICPC2+. Nationally recognised disease classification and terminology systems include ICPC2, ICD10-AM and SNOMED-CT.

Source: Practice Incentives Program eHealth Incentive guidelines—February 2013

DOCLE (Doctor Command Language) is a non-numeric health coding and medical classification system. The DOCLE system is used in Clinical.

DOCLE has been modelled on the Linnaean biological classification system since 1995. DOCLE generates clinical codes from ubiquitous health language using an algorithm, hence it is a human readable clinical coding system.