With the development of electronic health records, coding schemes are available to clinicians to describe patient care. An example of this is the Omaha System. The Omaha System is used to document client needs, describe practitioner interventions, and measure client outcomes.
Users include nurses, physicians, occupational therapists, physical therapists, registered dietitians, recreational therapists, speech and language pathologists, and social workers. When multidisciplinary health teams use the Omaha System accurately and consistently, they have an effective basis for documentation, communication, coordination of care, and outcome measurement.
The Omaha System consists of three components:
- Problem Classification Scheme-Organize assessment (needs and strengths) for individuals, families, and communities
- Intervention Scheme - Organize multidisciplinary practitioners’ care plans and the services they deliver
- Problem Rating Scale for Outcomes- Evaluate individual, family, or community change over time
Domains and Problems of the Problem Classification Scheme
Income
Residence
Neighborhood/workplace safety
Psychosocial Domain: Patterns of behavior, emotion, communication, relationships, and development.Some examples are:
Social contact
Role change
Interpersonal relationship
Spirituality
Growth and development
Physiological Domain: Functions and processes that maintain life. Some examples are:
Hearing
Vision
Speech and language
Cognition
Pain
Respiration
Health-related Behaviors Domain: Patterns of activity that maintain or promote wellness, promote recovery, and decrease the risk of disease.
Nutrition
Sleep and rest patterns
Physical activity
Personal care
Medication regimen
Categories of the Intervention Scheme:
Teaching, Guidance, and Counseling: Activities designed to provide information and materials, encourage action and responsibility for self-care and coping, and assist the individual/family/community to make decisions and solve problems.
Treatments and Procedures: Technical activities such as wound care or and medication prescriptions that are designed to prevent, decrease, or alleviate signs and symptoms of the individual/family/community.
Case Management: Activities such as coordination, advocacy, and referral that facilitate service delivery, improve communication among health and human service providers, promote assertiveness, and guide the individual/family/community toward use of appropriate resources.
Surveillance: Activities such as detection, measurement, critical analysis, and monitoring intended to identify the individual/family/community status in relation to a given condition or phenomenon. Concepts and Ratings of the Problem Rating Scale for Outcomes:
| Concepts | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|
| Knowledge:Ability of the client to remember and interpret information | No knowledge | Minimal knowledge | Basic knowledge | Adequate knowledge | Superior knowledge |
| Behavior:Observable responses, actions, or activities of the client fitting the occasion or purpose | Not appropriate behavior | Rarely appropriate behavior | Inconsistently appropriate behavior | Usually appropriate behavior | Consistently appropriate behavior |
| Status:Condition of the client in relation to objective and subjective defining characteristics | Extreme signs/ symptoms | Severe signs/ symptoms | Moderate signs/ symptoms | Minimal signs/ symptoms | No signs/ symptoms |
A full description of the components is available online here
The Omaha System model incorporates the circular, dynamic, interactive nature of the problem-solving process; the practitioner-client relationship; and concepts of critical thinking, clinical decision making, and quality improvement.
This is an example of an ABC code below- For other ABC Code structure examples see website
REFERENCES:
ABC (Alternative Billing Codes) Code Structure
ABC codes provide a more detailed description of health
care services to assure appropriate reimbursement. ABC codes were originally
developed to process claims addressing conventional, complimentary, and
alternative health care services not routinely included in traditional medical
billing codes.
Here is a link to the ABC code structure website
Each ABC code consists of a set of five alphabetic
characters that are used to identify services. These five characters are
organized in a hierarchical structure which groups similar products, remedies,
and supplies together. The five character code is then followed by a two
character code that identifies the type of practitioner who provided the
service reflected in the code. The ABC code is recognized by the American
Nurses Association (ANA) and is already integrated with other coding systems
including the Current Procedural Terminology (CPT) and the Healthcare Common
Procedure Coding System (HCPCSII).
REFERENCES:
ABC Code Set. (2015). “Find-A-Code.” Retreived January 30, 2015 from http://www.findacode.com/abc-codes-set.html
Garvin, J. H., Martin, K. S., Stassen, D., & Bowles, K. H. (2008). Omaha system: Coded data that describe patient care. Journal of AHIMA, 79(3), 44-49.
