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
Section Key Requirements for Coding Principal Diagnosis (PD) ONE condition per admissionMost serious or resource-heavyState clearly in summaryIf 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…
Date implemented – 05/2017Review date – nil plannedAuthor – Nuria O’Mahony / Mike Cadogan
