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MORE ON CODING
In the consultation that we have just seen with Micky Mouse, he presented with only one problem which presented little difficulty in terms of coding. Frequently however, patients present with more than one problem all of which need to be coded and it is important that you know how to deal with this.
There are two ways to add additional diagnoses. The first way is to use the menu choice A for Additional. I would recommend that you use this choice for problems directly related to the main problem coded. For example if Mickey is coded as having ‘shoulder pain’, and I issue a medical certificate for this I would use A to enter Medical Certificate Issued as a subsidiary code, with free-text stating the duration of the sick note.
However, let’s assume Micky also presents with a completely unrelated diagnosis of gout which we wish to code separately. If we press P again we will actually wipe-out our original coding. Therefore we use N for next problem. This prompts us to save our original coding (as if we had filed using F8). We can now use P again to enter our second coded diagnosis and we can subsequently add free text history and examination findings for this problem as before. Subsequently we can save and exit using F8, or add further diagnoses using N. In Consultation Mode the history and examination findings for the two problems will then be clearly separated.
Coding clinical
problems and findings correctly is absolutely crucial for the effective use of
the system. Information that has been
coded can be searched for and analysed.
Information that has been coded incorrectly or entered in free text will
never be found.
Let’s look at coding again. In this case we are going to code the heart failure that our patient Micky Mouse has. We type P to bring up our Problem List and type heart failure. We can see that there a number of menu choices continuing over several pages. What diagnosis should we choose?
It may in fact be true that he has Heart failure confirmed (Code 101). However as a general rule it is always best to code the root diagnosis of a significant problem, and then the more specific stem diagnosis if wished.
The reason for this is if we search for patients coded as Heart failure (Code G58) we will pick up stems of this code:
G580 Congestive heart failure
G582 Acute Heart Failure
G5800 Acute Congestive Heart Failure
but not alternative codes such as
101 Heart Failure Confirmed
14A6 H/O Heart Failure
or 1J60 Suspected Heart Failure.
In Mickey’s case if there is a specific reason to use Heart failure confirmed we need to ensure he is also coded as Heart failure (Code G58). Doing this means that you have a consistent code that will reliably pick up all patients with heart failure when searched for. The same applies across all other significant disease categories.
Accurate coding is also essential for values, such as
weight, blood pressure, smoking status etc; and for activities, such as smoking cessation advice, referral to
dietician declined, minor surgery done – injection.
However: “If it ain’t coded, it just ain’t loaded”.
For example you will be used to writing your history in free-text: “Blah blah blah blah blah blah, 180/110, blah blah blah blah blah. Haematuria. Blah blah blah blah blah. 198 kg. blah blah blah smokes 40/d blah blah advised stop smoking”. However a computer search for patients with hypertension, haematuria, obesity or smoking would fail to pick this patient up on all counts, unless these factors have been coded.
Let’s take blood pressure as an example. Enter BP as your
diagnosis: this will bring up the following menu choices. Choose O/E - blood pressure reading.
This will bring up the following dialogue:
Enter the systolic and diastolic readings respectively. The BP is now coded, and will appear in all the other sections throughout this patient’s computer records where BP is displayed, under today’s date.