Patient—primary body function or structure affected, body function or structure code N[N]

Guide for use:

This data element should be used in conjunction with the data element: Patient—additional body function or structure affected, body function or structure code N[N] to provide information on the nature of the harm alleged to have resulted from a health-care incident.

Only one primary body function or structure may be selected.

The primary body function or structure affected should be that which has the greatest impact on the patient.

Where this impact is psychological it should be recorded as Code 1 'Mental functions or structures of the nervous system'.

Where the patient experiences pain as a result of the health-care incident, record the code for the body structure with which the pain is most closely associated. Where the pain experienced by the patient as a result of the health-care incident is deemed to be more disabling than the associated physical or mental damage to the patient, then record Code 2 'Sensory functions and pain of the eye, ear and related structures'.

In the case of cancer primarily affecting a single organ or body part, the appropriate code for that organ or body part should be recorded. Where the cancer has progressed and affects major body systems, Code 4 'Functions or structures of the cardiovascular, haematological, immunological and respiratory systems' should be recorded. This rule should also be followed for other conditions affecting major body systems.

Comments:

This data element is fully aligned with the Australian Prudential Regulation Authority (2006) National Claims and Policies Database, data item 16. 'Body functions or structures affected'.