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
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