✅ Interactive Version – Implementation Plan ✅ V2 features: ✔ Principal Diagnosis (auto-complete)✔ Linked Causes (dynamic add fields)✔ Secondary Diagnoses (dynamic add fields + auto-complete)✔ Significant Procedures (dynamic add fields)✔ Optional Sections (Show/Hide): Infections, Fracture, Anaemia, Pressure Injury✔ Auto-complete using…
Coding Documentation Template (Demo Version) Principal Diagnosis Linked Cause(s) Secondary Diagnoses (with actions) Significant Procedures Optional Sections Infection Details Fracture Details Anaemia
Coding Documentation Template Simple structure with potential look – with ability to add extra fields, auto-complete, and export as copy and paste summary template for teh end of the written notes Principal Diagnosis Linked Cause(s) + Add Another Linked Cause…
Formulation of code stratification to facilitate drop-down/autocomplete fields 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…
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…
Rules & Key Elements for Each Section Principal Diagnosis (PD) Linked Cause (If Applicable) Secondary Diagnoses Procedures Specificity Requirements (These add coding weight, so missing detail costs money.) Clinical Significance of Abnormal Tests
