Utilising Coder Expertise

in

Clinical Documentation Education

Tracey Matthies

Senior HIM

Sunshine Coast Hospital & Health Service

Queensland Health

Reason for Admission/Presenting Problems

Referred by GP for episode of hypertension

Principal Diagnosis

Probably not pre-eclampsia

Other Active Problems

Nil Entered

Previous Medical History

Previous history of pre-eclampsia requiring ICU admission

Inpatient Clinical Management

Admitted under obstetric team for assessment and observation

Complications

Nil Entered

Procedures Performed

Nil Entered

Pathology

Nil Entered

Medical Imaging

Nil Entered

Significant Other Investigations

Nil Entered

Medications at Admission

Nil Entered

Medications at Discharge

Nil Entered

Medications Ceased this Admission

Nil Entered

Adverse Reactions

Nil Entered

Alerts

Nil Entered

Follow Up Arrangements

Nil Entered

Recommendations to GP

Nil Entered

Yeah, not so good….

Reason for Admission/Presenting Problems

CT guided lung biopsy to investigate lung nodule

Principal Diagnosis

Lung nodule

Other Active Problems

Nil Entered

Previous Medical History

COPD

Hypertension

Family history lung cancer – yearly CXR to monitor

Inpatient Clinical Management

Admitted under Respiratory for lung biopsy

Right pneumothorax after his lung biopsy - ICC inserted with resolution of pneumothorax

Episode of bradycardia following the ICC insertion – ECG reassuring but right bundle branch block noted

Transferred to ward for overnight stay due to pneumothorax

Pain treated with paracetamol and opioids

CXR in morning revealed resolution of pneumothorax – discharged home

Complications

Large right pneumothorax post lung biopsy

Procedures Performed

ICC

Pathology

Lung biopsy results pending

Medical Imaging

CXR 15/01/20xx

CT Guided Drain/Aspiration 15/01/20xx

CXR 16/01/20xx

Significant Other Investigations

Nil Entered

Medications at Admission

Aspirin – Codeine 325mg/8mg tablets

Medications at Discharge

Nil Entered

Medications Ceased this Admission

No medication changes

Adverse Reactions

Nil known

Alerts

Nil Entered

Follow Up Arrangements

Respiratory physician will call patient early next week to discuss the results of the lung biopsy and make further follow up as indicated

Recommendations to GP

Monitor RBBB and follow up as required

Recommendations to Patient

Take analgesia as required to treat pain

Respiratory physician will call next week to discuss results of biopsy

Care Plan Summary

Analgesia as required to control pain associated with biopsy

Way better!

Passive Learning

Not really getting

the message

through

Active Learning

Got their attention

now!

Advertising

The workshops bring together the expertise

and perspective of senior Consultant,

General Practitioner and Clinical Coder.

A supportive yet challenging environment for

the students to write real discharge

summaries from real health records and

get instant feedback from three of their

most important readers

Interactive Workshop

Sunshine Coast Hospital and Health Service

in conjunction with the University of

Queensland, School of Medicine,

Sunshine Coast Clinical School

„Interactive with immediate feedback, best

“on the job” type teaching we‟ve had‟

Interactive Workshop

The Educators

Specialist Medical Officer (SMO)

General Practitioner (GP)

Enterprise Discharge Summary Facilitator (EDS)

Clinical Coders

The Students

4th Year Medical Students

„Different perspectives from coders, medical staff and GP. Practical experience in using / troubleshooting EDS. This was a great session – would recommend every 4th year

do it.‟

Interactive Workshop

Materials:

EDS Guidelines

Computers

Health Records

„Real charts from your ward – very meaningful‟

Interactive Workshop

Interactive Workshop

Format

Group Discussion

- Role of health record documentation

- Various readers and their expectations

- GP expectations & professional courtesy

EDS system overview

- Layout

- Feeder systems

- Short cuts

„Very clear information and relevant info. Different staff to provide different views about what‟s important to them‟

Interactive Workshop

Format (con’t)

Writing the discharge summary

- Abstracting information from the health record

- Presenting information on the discharge

summary

Discharge Summary Reviews

- Critiquing a few

„Incredibly relevant and real practice doing reports

with direct feedback‟

Interactive Workshop

Discussions that arose

What is considered relevant information

Where should it go – PD, AD, complication

Writing a diagnosis not a value

Gleaning information from progress notes

The discharge plan – instructions, medications

Deceased patients

„Practical; provided a number of different perspectives on discharge summaries and the

importance of doing them correctly‟

Interactive Workshop

The expertise the coder can share

Trust me

I‟m a Coder

The expertise the coder can share

Definition of terms used in the

discharge summary

– Principal Diagnosis

– Other Active Problems (AD)

„Good structure provided that is not otherwise

taught‟

The expertise the coder can share

Explaining the format of the discharge

summary – Reason for Admission/Presenting Problem

– Principal Diagnosis

– Other Active Problems

– Previous Medical History

– Inpatient Clinical Management

– Complications

„Great friendly coding staff were very helpful. Interactive‟

The expertise the coder can share

Identifying the diagnoses to include

– Including providing a diagnoses not a value

„Very practical and from workers in area e.g. GP,

coders‟

The expertise the coder can share

Explaining where to find the information in

the health record

– Pointing out the relationship between

progress notes and discharge summary

„Interactive. Lots of advice / people to ask for help‟

What the Coder Learns

What the coder learns

They have strong skills to share

- Coders are the expert readers

- Coding is all about summarising clinical

concepts

- Coders are expert abstractors

- Coders know their way around a health

record

„Great session to debunk the fear of the unknown!‟

What the coder learns

How a clinician thinks when they are

documenting - They don‟t have a full awareness of who is

going to be reading it or why

- They don‟t think like a coder (coders want the outcome clinicians want the detail)

- They don‟t use coding language so learn to translate

„Range of expert opinion to give and wider understanding and diversity of expectations (e.g.

consultant / GP / coders‟

What the coder learns

They can develop professional relationships

with clinicians

- They are professional/experts within their

own field and can be respected for that

- Clinicians are willing to work with coders and

take direction

„Good use of GP, coders and clinicians‟

Building the Relationship

and Skills

Building the Relationship and Skills

Effective documentation queries

- Now that the clinician knows who you are

and what your purpose is he will read your

query

- Identifying if a query to the clinician is

required

- Writing a query in the clinician‟s language

- Constructing the question to get an answer

- Using documentation queries to provide

feedback on documentation quality

Query:

Could you please confirm if depolarisation (as per the codes below) is the same as repolarisation?

There doesn't seem to be a code for Repolarisation that I can use.

If it is the same then you may be able to recommend the best one to use.

We have been asked to use Chest pain as a last resort if no cause is documented so if these terms don't have the same meaning then you may be able to suggest an alternative.

Response:

Physiologically depolarisation and repolarisation are not the same thing.

Without context I couldn't tell you what to code for repolarisation. I don't remember this gentleman and without his chart I couldn't offer any more suggestion as to whether chest pain was appropriate. Sorry.

Yeah, not so good…..

Query:

Admission for bilateral inguinal hernia repair with no hernia found. There was documentation on the op report of sigmoid epiploic appendage adhered to deep ring- resected free, some omentum adhered to right deep ring but no hernia present.

My questions relating to this procedure and the findings:

1. As no hernia was found, what was the presenting symptoms?

2. After study, has there been any formal diagnosis to explain the cause of the presenting symptoms?

Response:

Give me a call if it is confusing

1. I think still we can say hernia was present in both side, because in some cases we cant see a peritoneal sac.

2. I think those fat and epiploic appendage was herniating, so B/L hernia is the diagnosis

Way better!

Building the Relationship and Skills

Participating in clinical meetings and clinical

education

- Clinicians appreciate the value of having

coder input into documentation

- Clinicians want to utilise the abstraction

skills of a coder

Suggestions for improvement

• „Doing a practice case together in the start

to practice extracting data‟

• „Structure of charts and tips for sourcing

patient info‟

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