Clinical Coding
As well as being able to attach basic appointment notes and documentation to the patient record, Med+DBase also has an advanced consultation suite based around the internationally recognised coding system, SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms)
Customised clinical forms can be created within Med+DBase and attached to the corresponding appointment types which in turn capture all medical data, varying from the patients' past medical history and social habits, to the number of alcohol units consumed per week.
Each field within the clinical form has a SNOMED CT term and clinical statement attached. As data is entered into the clinical form, it is associated with the term and attached to the patient record medical history.
Data is automatically captured and saved as you type and the match process of free text to SNOMED CT is carried out automatically by Med+DBase in the background.
There are many advantages relating to the recording of information in a standard and structured format terminology such as SNOMED CT. These in turn are linked to the electronic care record and the recording of clinical information in a structured form. Some of the key benefits are:
- It provides a consistent terminology across all care domains including the NHS
- It allows precise recording of clinical information
- It has an inherent structure
- It is a developing international standard
For further information on SNOMED CT, please visit the following sites:
Numerical data values can also be tracked as part of the consultation suite allowing clinicians to monitor heart rates, blood pressure, BMI etc., over periods of time and set threshholds on those values.
Once the patient information has been captured into the clinical form, meddbase gives the clinician the option to assign appointment episodes to cases. This builds up a case history for the patient allowing easy retrieval of notes on specific episodes that relate to the current case. Along with the date and time, it details exactly what happened in previous episode and the clinician who attended.
Clinicians can also record multiple episodes and cases within the same appointment allowing them to treat patients for different symptoms, while keeping the integrity of the patient record.
When reviewing the patient record Med+DBase has a detailed medical tree that in turns displays all patient history within a log of events. The medical log can be set to display all events relating to the patient’s medical record, or alternatively, using the tree, you can drill down on to a specific area. For example, past medical history or previous complaints. Using the tree you may also drill down on to a specific SNOMED CT term and furthermore display a log relating to each time and in which context the term has been mentioned on the medical record.
The tree displays all events relating to the patient record including attached documentation and prescriptions.