On admission, the ward staff stick an orange dot label on the front of the patient notes. This is only removed by a Clinical Coder when the activity has been coded.
We are on track this year to see a 12% increase in the number of cases where the casenotes are used for Clinical Coding.
Good Clinical Coding relies on access to the very best information available. Although we have lots of clinical systems, the full casenotes are a further valuable resource to ensure that coding is as complete as it can be.
Now, if a set of casenotes arrives late into the Coding office, the team can tell at a glance that they have not been used for coding.
As time allows, the coding can be re-visited and the additional information added. This all improves quality!
Medical records staff know never to file notes displaying an orange dot. They are diverted straight to the Coding office for review.
Clinical Coding is the translation of clinical documentation into a coded form so it can be used for analysis and benchmarking.
It also ensures the Trust charges the appropriate tariff for the care that patients receive. A simple solution but highly effective!