Dr Shyh yh Min Liew Foundation Year 2 Doctor University Hospitals - PowerPoint PPT Presentation

Dr Shyh yh Min Liew Foundation Year 2 Doctor University Hospitals of Leicester NHS Trust United Kingdom

 To look at the accuracy of Primary Diagnosis and co- morbidities in discharge letters and its corresponding ICD-10 code.  Improving information given to patients at discharge.  Increase awareness amongst medical professionals the importance of accurate details in the discharge letters and its relation to clinical coding.

 All discharge letters should have a diagnosis as per the most recent consultation with a senior paediatrician  All discharge letters should have up to date co-morbidities

 Review of 50 discharge letters from across all paediatric wards in the month of August 2014.  Comparing diagnosis written in discharge letters against ward rounds/clerking entries in the corresponding patient notes.  Tariffs obtained from coders.

 13 out of 50 discharge letters (26%) had inaccurate/uncodable diagnosis.  6 out of 50 case notes (12%) had co- morbidities that were not included on discharge letters.  These notes will be coded based on symptoms, which generates less income.

 Information governance  Good record keeping  Contributes to the clinical data pool, used a lot in extracting samples for research/audits.

Words to use Not to use  Diagnosis/ working  ? diagnosis  Differentials  Likely/Most likely  Clinically relevant  Possible  Probable  Investigated As  Treated As  Impression  Presumed  Maybe  Suspected Examples:  Anaemia  Low Hb  Hypokalaemia  K+

Constant intermittent Constipation   crying Actually… PA26B  PA56B  £ 580  £ 524  £ 56 56

Abnormal Movements Seizure   Actually… PA01B PA03A   £ 726 £ 843 843   £ 117 17

Floppy, unresponsive, Atonic Seizure   incontinent, drooling Actually… PA02B  PA56B  £ 694 £ 524   £ 170 70

DIB, Wheeze Asthma   PA65A PA12Z Actually…   £ 354 £ 654   £ 300 00

 13 out of 50 discharge letters (26%) had inaccurate diagnosis.  7 examples = £ 1359 less income  Imagine the number of patient discharged from our services each month!

 Remember the Do’s and Don’ts  Consultants and Registrars – include final or most probable diagnosis before discharging patients.  Junior doctors writing discharge letter – please look through the notes for the appropriate diagnosis.  Education to final year medical students  Re-audit scheduled for October 2015

Dr. S Shyh h Min Liew shyhmin.liew@nhs.net