Coding Documentation Template (CDT)

Structured Coding Documentation Template

(Designed for typed entry with guidance examples in grey italics)

---

Section 1: Principal Diagnosis

Principal Diagnosis:

Linked Cause (if applicable):

---

Section 2: Secondary Diagnoses (Include Actions Taken)

---

Section 3: Significant Procedures (Include Reason)

---

Section 4: Trauma / Fracture Details (if applicable)

Site:
Laterality:
Open/Closed:

---

Section 5: Infection Details (if applicable)

Source:
Organism:

---

Section 6: Pressure Injury (if applicable)

Stage:

---

Section 7: Anaemia (if applicable)

Type (Acute/Chronic):
Cause:

---

Section 8: Electrolyte Disorders (if applicable)

---

Section 9: Chronic Conditions Impacting Care

---

Section 10: Clinical Significance of Abnormal Tests