What is the process of converting medical record information into standardized codes within a uniform data set called?

The process of converting medical record information into standardized codes within a uniform data set is referred to as abstracting. During abstracting, relevant data is extracted from patient medical records and then summarized or coded in a way that allows for uniformity in data reporting and analysis. This is essential for ensuring that the information can be consistently used for statistical analysis, research, and health management purposes.

Abstracting typically involves identifying key elements such as diagnoses, treatments, and outcomes, and translating those elements into codes that conform to established classification systems like ICD (International Classification of Diseases) or CPT (Current Procedural Terminology). This standardization is critical for data compilation across different healthcare providers and systems, enabling enhanced communication, research, and public health reporting.

In contrast, the other options like data entry refers to the act of inputting data into a system without the key conversion to codes, auditing pertains to reviewing and verifying data accuracy and compliance, and coding specifically involves the technical process of assigning codes to diagnoses and procedures after the data has been abstracted. Thus, while all these processes are interconnected in managing health information, abstracting encompasses the comprehensive act of condensing and standardizing data from medical records.