Classification systems in health services

-Automatic translation

Registration in medical records must be reliable and timely and reflect the health services provided. In addition, registration must follow specific standards and procedures to ensure reliability and realistic comparison of the health care provided within and between healthcare institutions and regions. Standardised registration includes, for example, the coding of clinical information using internationally recognised classification systems. The Directorate of Health issues instructions on which classification systems should be used for recording medical information in health services in Iceland.

Registration in Icelandic health services is thus based on accessible and appropriate classification systems by recommendations on minimum recording and guidelines.

All healthcare practitioners who record information in medical records must use the coded classification systems recommended by the Directorate of Health. This group of healthcare practitioners includes physicians, nurses, and medical secretaries. Several other health professions also use coded classification systems for registration.

Coordinated registration of health information

All health institutions must ensure that medical data is registered and that coded classification systems recommended by the Directorate of Health are used.

All software used to register health data must always provide access to current versions of the classification systems recommended by the Medical Director of Health.

The website SKAFL.is publishes current versions of classification systems

• ICD-10. All diagnoses should be registered by the International Classification of Diseases and Related Conditions, Rev. 10.

• NCSP. Surgical procedures shall be registered according to the NOMESCO Classification of Surgical Procedures or NCSP-IS, a national version of the classification system, which includes a more specialised registration.

• NCSP-IS. Registration with NCSP-IS is more detailed than the NCSP classification system, as in recent years, countries have developed their own NCSP country codes. NCSP-IS is recommended when recording surgical procedures, particularly regarding DRG.

• ICNP. The International Classification for Nursing Practice is made for coordinated registration in nursing. Icelandic translation is available online on the International Council of Nurses website. Please note that English is the default language in the browser, so you need to change the language to see the Icelandic version.

• ICF. The International Classification and Functioning, Disability, and Health are intended for the coordinated registration of health-related skills.

• SNOMED-CT. The Directorate of Health has a national license for using the international coding system SNOMED-CT, which has been used in Iceland for many years for coordinated registration in pathology, virology, microbiology, and immunology. The classification system is not available in Icelandic, but the English version can be found on the SNOMED International website.

The Directorate of Health oversees these classification systems' translation, development, updates, publication, and distribution in consultation with foreign responsible parties.

Other classification systems in use

Other classification systems are also in use in Iceland. All pharmaceutical prescriptions are registered according to the Anatomical-Therapeutical-Chemical Classification.

2016, the Directorate of Health established a professional council on classification systems. The council's role is to formulate a policy on classification systems in health services in Iceland, define and prioritise essential projects, and act as a professional adviser on coding issues. The professional council comprises ten experts with significant experience in coding in healthcare.