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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 - - 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
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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.
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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
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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.
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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.
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Information governance Good record keeping Contributes to the clinical data pool, used a
lot in extracting samples for research/audits.
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Words to use Not to use
Diagnosis/ working
diagnosis
Clinically relevant Probable Treated As Presumed ? Differentials Likely/Most likely Possible Investigated As Impression Maybe Suspected
Examples: Anaemia Hypokalaemia Low Hb K+
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Constant intermittent crying
PA56B
£524
Constipation
PA26B
£580
Actually…
£56 56
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Abnormal Movements
PA01B
£726
Seizure
PA03A
£843 843
£117 17
Actually…
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Floppy, unresponsive, incontinent, drooling
PA56B
£524
Atonic Seizure
PA02B
£694
Actually…
£170 70
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DIB, Wheeze
PA65A
£354
Asthma
PA12Z
£654
Actually…
£300 00
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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!
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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
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- Dr. S
Shyh h Min Liew
shyhmin.liew@nhs.net