- 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)
Formulation of code stratification to facilitate drop-down/autocomplete fields
- Extract common conditions from original coding guidelines and national coding standards (ICD-10-AM / ACHI / ACS).
- For each condition, provide:
- Full description (no abbreviations)
- Example of best-practice documentation phrase
- Linked treatment actions (to increase DRG weight)
- Structure as:
- Condition | Preferred Wording | Example Treatment
- Group into:
- Medical Core Conditions (e.g., Pneumonia, COPD, Heart Failure)
- Common Surgical Conditions (e.g., Appendicitis, Post-op complications)
- High-Value Secondary Diagnoses (e.g., Hypokalaemia, Sepsis, AKI)
- Chronic Conditions (e.g., Diabetes, CKD, COPD)
If And Then Process
| Condition | Preferred Wording | Example Treatment |
|---|---|---|
| Hypokalaemia | Hypokalaemia (not “low K”) | IV potassium replacement, ECG monitoring |
| Atrial Fibrillation | Atrial Fibrillation | Rate control with beta-blocker, anticoagulation |
| Anaemia | Acute blood loss anaemia due to GI bleeding | Packed RBC transfusion, iron infusion |
| Sepsis | Sepsis due to Streptococcus pneumoniae | IV antibiotics, blood cultures |
| Acute Kidney Injury | Acute Kidney Injury (AKI) | IV fluids, nephrology referral |
| Pressure Injury | Pressure Injury Stage 3 | Pressure relief mattress, dressings |
Functional process set up for stage 3:
✅ Loaded as auto-complete dropdowns in form fields. (Table text)
✅ Suggest BEST phrase when clinician types a keyword (e.g., typing “low K” auto-suggests “Hypokalaemia – IV potassium given”).
Master Auto-Complete List (ED Focus)
(Full wording – no abbreviations – plus treatment examples to maximise DRG weight)
- All are high-value DRG drivers in Emergency and inpatient coding.
- Wording is aligned with Australian Coding Standards (ICD-10-AM).
- Includes management actions for maximum funding.
| Condition | Preferred Documentation | Example Treatment / Action |
|---|---|---|
| Electrolyte Disorders | ||
| Hypokalaemia | Hypokalaemia | IV potassium replacement, ECG monitoring |
| Hyperkalaemia | Hyperkalaemia | Insulin/dextrose infusion, calcium gluconate |
| Hyponatraemia | Hyponatraemia | Fluid restriction to 1L/day, hypertonic saline |
| Hypernatraemia | Hypernatraemia | IV hypotonic saline, monitoring |
| Hypocalcaemia | Hypocalcaemia | IV calcium, ECG monitoring |
| Renal / Metabolic | ||
| Acute Kidney Injury | Acute Kidney Injury | IV fluids, nephrology referral |
| Chronic Kidney Disease Stage X | Chronic Kidney Disease Stage X | Fluid balance monitoring, renal profile |
| Metabolic Acidosis | Metabolic Acidosis | IV bicarbonate, treat underlying cause |
| Respiratory | ||
| Pneumonia | Pneumonia due to Streptococcus pneumoniae | IV ceftriaxone and oral doxycycline |
| Community-Acquired Pneumonia | Community-acquired pneumonia | IV antibiotics, oxygen |
| Aspiration Pneumonia | Aspiration pneumonia | IV antibiotics, suction, NBM |
| Chronic Obstructive Pulmonary Disease | Acute exacerbation of chronic obstructive pulmonary disease | Nebulisers, steroids, oxygen |
| Asthma Exacerbation | Acute asthma exacerbation | Nebulisers, steroids |
| Cardiac | ||
| Atrial Fibrillation | Atrial Fibrillation | Rate control with beta-blocker, anticoagulation |
| Acute Coronary Syndrome | Acute coronary syndrome | Aspirin, heparin, beta-blocker |
| Heart Failure | Acute decompensated heart failure | IV frusemide, oxygen, nitrates |
| Infection / Sepsis | ||
| Sepsis | Sepsis due to [organism] | IV antibiotics, blood cultures, fluids |
| Cellulitis | Cellulitis | IV antibiotics |
| Urinary Tract Infection | Urinary tract infection | Oral/IV antibiotics |
| Bacteraemia | Bacteraemia | IV antibiotics, blood cultures |
| Neurology | ||
| Stroke | Acute ischaemic stroke | CT brain, thrombolysis if eligible |
| Seizure | Generalised tonic-clonic seizure | IV benzodiazepines, airway support |
| Delirium | Acute delirium | Identify cause, reorientation, antipsychotic if needed |
| Haematology | ||
| Anaemia | Acute blood loss anaemia due to gastrointestinal bleeding | Packed RBC transfusion, IV iron |
| Thrombocytopenia | Thrombocytopenia | Platelet transfusion, treat cause |
| Coagulopathy | Coagulopathy secondary to anticoagulant | Vitamin K, prothrombin complex concentrate |
| Endocrine | ||
| Diabetic Ketoacidosis | Diabetic ketoacidosis | IV insulin, fluid resuscitation |
| Hyperglycaemia | Severe hyperglycaemia | IV insulin, hydration |
| Hypoglycaemia | Hypoglycaemia | IV dextrose, monitoring |
| GI / Hepatic | ||
| Upper GI Bleed | Upper gastrointestinal bleed | Endoscopy, IV proton pump inhibitor |
| Lower GI Bleed | Lower gastrointestinal bleed | Colonoscopy, IV fluids |
| Pancreatitis | Acute pancreatitis | IV fluids, NBM, analgesia |
| Skin / Pressure Injury | ||
| Pressure Injury | Pressure injury Stage X | Pressure mattress, wound care |
| Trauma | ||
| Fracture Femur | Closed fracture of left femur | ORIF with intramedullary nail |
| Fracture Radius | Closed fracture of distal radius | Closed reduction, cast immobilisation |
| Head Injury | Head injury with concussion | CT brain, observation |
| Laceration | Laceration of forearm | Wound cleaning, suturing |