TIM WALTER wrote:
>> Hi
>> I would be most interested in how you annotate/change your patients
>> EMR upon the discovery of a new diagnosis for a patients symptoms ( I
>> am loath to use the word Misdiagnosis!). I cannot find any
>> guidelines for this. Leaving in original codes for the diagnosis has
>> implications for QoF, but then again there is the question of
>> preserving the visibler record (audit trails excepted of course).
>>
>> Tim Tilbrook
>> Clinical Data Manager
>> Bradford
>
>
> In Emis, if you delete the "wrong code" and replace it by the
> revised one (Actually add the revised code then delete the
> old one and indicate which code to replace it with) then the notes
> actually are amended to
>
> (Chest Pain) Replaced with Angina
>
> Thus the record is amended, the alteration displayed, and the Read
> codes suitably changed.
>
> HTH
We've found ourselves changing records in the other direction - where a
definite "Angina" code was entered on the basis of a clinical diagnosis
which wasn't subsequently confirmed by ETT, we've had to change this to
"Chest pain on exertion". We tend now to use symptom codes if we can't (yet)
substantiate diagnoses with the necessary tests.
Which raises the question, should we always work backwards from the answer
and adjust earlier codes?
My feeling is that the sequence of consultations going URTI->Nocturnal cough
following URTI->Asthma should remain that way, and the diagnosis of asthma
shouldn't be retrospectively attached to the first consultation. Only if an
earlier diagnosis (or coding of symptoms) is found to be wrong should it be
amended.
Michael
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