Most junior doctors will be aware that hospitals employ Clinical Coders. Clinical Coders read all of your clinical notes and attempt to collate a list of diagnoses and procedures for each patient. Your hospital is then funded according to the codes obtained. Obviously, the higher the acuity and complexity of a patient encounter then the higher the funding obtained.
Obviously then the work of the Coders is reliant upon your clinical notes, and how accurate and how complete they are. Therefore Coding becomes a surrogate marker of the quality of your clinical notes.
We have been provided by the Coders with some examples of how much difference the correct terminology can make to costings. You should also consider the difference this makes to other clinicians who are reading your notes at a later date. This extends to the General Practitioners who will continue to manage your patients in the community. The example of ceasing frusemide is a simple illustration – the GP needs to know exactly why the frusemide was ceased, just as much as the Coder does.
We will provide you with further examples through C-foam and through other forums, because we believe that the standard of our clinical notes is crucial to good patient care and outcomes.
You may also like to download the Activity Based Funding App, which will give you some useful hints and act as a good reference tool. It is available for both ios and android devices.