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How to Add Clinical Codes

Kevin Wall Updated by Kevin Wall

This article will show you how to add clinical codes from information in the documents.

The system allows you to use the Optical Character Recognition (OCR) software to add coding information from the documents into your clinical system.

Whether it's READ or SNOMED, the system will help you put the information into the system using various tools to suggest codes, or simplify the process of adding the information to the patient record.

Create a Clinical Coding Task

Clinical coding tasks must be created to allow you to use the tools in the system. These can be created in 3 ways.

  1. Coding Task - In your Task inbox, if you have been sent a Coding type Task, you will have extra actions available in the Task Actions panel on the right when you select the Task in your inbox.
  2. Add Clinical Codes - In the Patients Documents screen, with a document selected, the Document Actions panel will have an option named Tasks. Select, a further list will display Add Clinical Codes. This will create a Coding Task in your inbox and take you to it.
  3. When Filing, in the Create Review field, there is a tick box named Start Clinical Coding immediately after filing. Select this, alongside any reviews if required, this will create a Coding Task in your inbox, and take you to it. The document will be filed when you select Save, and any further review(s) chosen using your templates will be sent simultaneously.

Clinical Coding Tasks

To identify a Coding Task, the card has CODING prefix.

A Coding Task has 3 added Actions in the panel on the left. These are:

  1. Add Code with Browser - this opens the Clinical Code Browser pop up allowing you to type in the code name or number you wish to add to the patient record.
  2. Add Code from Predefined List - Opens a list of locally configured predefined codes that you can pick from. This list is managed locally, so you can add regularly used codes to save time having to find them using the previous option.
  3. Add BP Reading - The system will look for BP readings, if it finds any it recognises in the document, this field will go bold and show: Add BP Reading - Found 1. By selecting this, it opens a window allowing you to select the purple highlighted BP in the document and this will add the Systolic and Diastolic values into the entry ready to submit to the patients record.

Beyond the three features already mentioned, the Coding Task also lets users highlight text within the document. The cursor changes to a crosshair when it's moved over the document image to facilitate this highlighting.

  1. Click and drag the crosshair across a word or phrase to highlight the text.
  2. Release the mouse button to prompt the system to search the Code lists and offer 5 best matching Clinical Codes in the field on the right.
  3. Select a Code or Term from the list presented.

Selecting the Notes field and using the same process, text can be copied from the document into the Notes field.

Values can also be selected in the same manner, by first selecting Value field, then finding and highlighting the corresponding values in the document.

When you're happy with information you've added for the term:

  1. Select Confirm and the detail moves over to the right so that you can continue to add further Codes.
  2. The selected Codes are sent to the patient record in the clinical system when you select Finish or Save.
  • Finish will send the Codes and complete your active Coding Task.
  • Save will send the Codes, and leave the Coding Task in your inbox if further actions are required.

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