Global COVID-19 Clinical Characterization Case Record Form

In the wake of COVID-19, I have been thinking how coronavirus data is been captured into a typical medical record. A check around the Internet led me to the World Health Organisation [WHO] recommended rapid clinical characterisation case record form (clinical CRF).

Like the one standardised form i.e. The World Health Organisation (WHO) International Form of Medical Certificate of Cause of Death to collect mortality data among member states—with the clinicial CRF form also by the WHO, the WHO intends that by using one standardised clinical data tool, there is potential for clinical data from around the world to be aggregated; in order to learn more to inform the public health response and prepare for large scale clinical trials.

This form is intended to provide member states with a standardised approach to collect clinical data in order to better understand the natural history of this disease and describe clinical phenotypes and treatment interventions (i.e. clinical characterisation) for Covid-19.

Some important stuff to take note if implementing this form include:

1: this CRF has 3 (M)odules to be completed—(M1)for first day of admission to the health centre, (M2) on first day of admission to ICU or high dependency unit, also be completed daily for as many days as resources allow and continued to follow-up patients who transfer between wards, and (M3) to be completed at discharge or death; and,

2: Internet services are required to enter data to the central electronic REDCap database or to your site/network’s independent database; the form guidelines suggest that printed paper CRFs may be used and the data can be typed into the electronic database afterwards.

The form can be viewed from the link (the link will open in a new tab of your current window) in the reference given below.

Reference:
Coronavirus disease (COVID-19) technical guidance: Patient management, Case Management, WHO, <https://www.who.int/docs/default-source/coronaviruse/who-ncov-crf.pdf?sfvrsn=84766e69_4>

ICD Coding advice from the WHO for the 2019 novel coronavirus (COVID-19)

The purpose of this post is to share the World Health Organization [WHO] official diagnosis coding guidance update for health care encounters and deaths related to the 2019 novel coronavirus (COVID-19) previously named 2019-nCoV.

Screenshot image from ICD-10

ICD-10 Chapter XXII: Codes for special purposes has a special sub-category called U07 Emergency use of U07. WHO’s recent creation of an emergency ICD-10 code U07.1, is assigned to the disease diagnosis of 2019-nCoV acute respiratory disease. See my screenshot image from ICD-10 to the left.

 

The title of U07 will be changed back to ‘codes for emergency use’.

It is to be noted that the name ‘2019-nCoV’ is temporary and is likely to change (to be independent of date and virus family, and for consistency with international virus taxonomy).

For ICD-11, the code for the illness would be RA01.0

A new and final ICD-10-CM code title for the COVID-19 diagnosis code is now [March 17–18, 2020] been established, and will be implemented effective October 1, 2020, by the Centers for Disease Control and Prevention’s (CDC), USA and the National Center for Health Statistics (NCHS), USA.

References:

  1. Emergency use ICD codes for COVID-19 disease outbreak, Classifications, WHO, <http://www9.who.int/classifications/icd/covid19/en/>
  2. Organizations Developing New Codes for COVID-19, and a Primer on the Virus, Under the Dome, Journal of AHIMA, <https://journal.ahima.org/new-icd-10-cm-code-for-covid-19-becomes-effective-october-1/>