A modern healthcare system such as the one in Germany is characterised by a high level of cooperation and communication networking on a functional, sectoral, regional, national, European and international level. To ensure communication between various areas requires common languages, i.d. standardised terminologies/ terminological standards. These do not only have to be unambiguous in human-to-human communication, but have to be equally without ambiguity if the communication chain included electronic system.
Patient records in a hospital or a doctor's surgery serve to document and optimise treatment. They are individual to each doctor and focus on the treatment; for that reason, they are written in varied and very detailed specialist medical terminology.
ICD-10-GM is a classification of diagnostic terms with parallel machine-readable codes. Its primary purpose is the encoding for billing and statistics; the formation, designation and scope of individual classes is guided by these purposes.
The application of ICD-10-GM to the documented disease descriptions generalises their content and reduces the language to mandatory unambiguous preferred terms; the descriptions in clear text are assigned an unambiguous machine-readable code. Mandatory sector-specific encoding guidelines ensure a uniform application across Germany.