- Overview of coding principles
- Coding Documentation Template (CDT) – with text boxes
- Master list (Principles)
- Coding Documentation Template (BASIC)
- Coding Documentation Template (with Auto-Complete)
- Coding Documentation Template (v1) depreacted
- Coding Documentation Template (v2)
| Section | Key Requirements for Coding |
|---|---|
| Principal Diagnosis (PD) | ONE condition per admission Most serious or resource-heavy State clearly in summary If uncertain: use probable/likely |
| Secondary Diagnoses | Include any condition that: → Requires treatment, monitoring, or tests → Increases complexity/resources – Link cause and effect (e.g., Anaemia due to blood loss) |
| Specificity | Fracture: site, laterality, open/closed Pressure injury: stage Infection: organism Anaemia: type & cause Multi-organ failure: all organs listed Cardiac: angina type, AF treatment |
| Procedures | List all procedures Include reason (why performed) |
| Medications | Link drug to diagnosis Document changes & reasons |
| Tests | Interpret results clinically- Note if abnormality treated or monitored |
| Discharge Summary | PD clearly stated All significant conditions & interventions included |
| Common Pitfalls | Don’t use symptoms alone Don’t record events instead of injuries Avoid vague terms (e.g., “infection”) |