Inaccurate discharge summary

ICD-10 and OPCS4 codes recorded for SMRs

Diagnosis# femur, diabetes, cataract S72.90 Closed fracture of femur, part unspecified

X59.9 Unspecified accident in unspecified placeE14.9 Unspecified diabetes without complications H26.9 Cataract. unspecified

OperationsReduction fractured femur W22 9 Unspecified primary open reduction of fracture of bone

Z76.9 FemurAccurate discharge summary

lCD-10 and OPCS4 codes recorded for SMRs

Diagnosis Compound fracture shaft of right femur.

S72.31 Open fracture of shaft of femur

Fall on icy pavement. W00.4 Fall on street involving ice or snowType 2 diabetes with diabetic cataract.

E11.3D Non-insulin dependent diabetes with ophthalmic complicationsH28.0A Diabetic cataract

Moderate hypertension I10.X Essential hypertensionLives alone. Z60.2 Living aloneOperationsReduction of fracture right shaft of femur, with Ender nail.

W19.3 Primary open reduction of fracture of long bone and fixation using flexible nailZ76.4 Shaft of femur

When a patient is discharged, hospital doctor completes discharge summary with details of patient’s condition and care and sends to GP

Hospital Doctors

The main aim of the discharge letter is to

communicate with the GP, and is also available

to the coder.

Discharge Summary

patiENt’s Gp MEDical rEcorDs DEpt

Coder translates details in discharge summary into code (diagnostic

information into ICD-10, operations /procedures into OPCS4) for SMRs.

isD scotlaND

SMRs are completed for all patients treated in Scottish hospitals: inpatients, day cases and outpatients in acute, maternity, mental health and long stay specialties. These data are held in the NHSiS databases at ISD.

iNForMatioN is UsED For:Feedback to clinicians o• n their own patientsResearch•Epidemiology•Clinical audits - local and national•Comparisons between, treatments, specialities,•health boardsOutcomes•Planning and management in the NHSiS•Appraisal•

coDEr statisticiaNs

Example:A 75 year old woman is admitted after falling on an icy pavement sustaining a compound fracture to the shaft of the femur in her right leg. She has diabetes controlled by diet. She is awaiting treatment for a diabetic cataract. Her blood pressure is 140/100mmHg. She lives alone and she will need convalescence in another unit when she is discharged. On the day after admission, the patient goes to theatre for reduction of the fracture and fixation using an Ender nail. She makes an uneventful recovery and is discharged to a unit for convalescence.

Coders can only code the diagnostic

and procedural information

given to them by the clinicians.

i n f o r m a t i o n f l o w f r o m h o s p i t a l c l i n i c i a n s t o n a t i o n a l d a t a b a s e

Hospital

SMRsSMRs (Scottish Morbidity Records) are collected for patients treated in hospitals throughout Scotland. SMR data are processed and analysed by Information Services Division of National Services Scotland in Edinburgh.

WhO IS ReSPOnSIble fOR ClInICAl InfORMAtIOn On SMRS?

Clinicians and coding staff are jointly responsible for providing accurate data on the SMRs. Clinicians must ensure all relevant information is available to the coder; coders must accurately translate this into ICD-10 or OPCS4 code. They are trained how to do this.Diagnostic and procedural data for SMRs may be obtained from a discharge summary, patient’s case notes or a proforma depending on each hospital’s practice.Where a clinical (or discharge) summary is used as the source document for coding, it should be:

structured•precise•prepared by a senior member of the team•signed and dated•

Please see over for details

Advice on clinical coding issuestel: 0131 275 7283email: NSS.terminologyhelp@nhs.net

Coding and terminology information for clinicians available at: www.isdscotland.org/Products-and-Services/Terminology-Services/Information-for-Clinicians/

Information on ISD Scotland’s confidentiality policies can be found at:

www.isdscotland.org/About-ISD/Confidentiality

Requests for statistical analysis andinformation from the national databasetel: 0131 275 7777

Discharge SummaryWhAt ShOUlD be ReCORDeD UnDeR DIAGnOSeS?

Main conditionThe condition PRIMARILY responsible for the patient’s need for treatment or investigation during this episode of healthcare. If there is more than one, select the one responsible for the greatest use of resources. If no diagnosis is made, record the main symptom, abnormal finding or problem.

Other conditions Record any conditions that co-exist or develop during the episode of healthcare which affect the management of the patient.Remember to include:

where one disease is the underlying cause of another•site and histology of all primary and secondary•neoplasms where knownwhere a condition is a late effect of a previous problem•where a condition is the direct result of a procedure•abuse or addiction to drugs and/or alcohol where this•affects patient managementdrug/chemical responsible for overdose/poisoning or•adverse effecttype of injury and how it happened•home or family circumstances where these affect•patient care

WhAt ShOUlD be ReCORDeD UnDeR OPeRAtIOnS?

Main operation

Record the main operation/procedure that was performed, the date it took place and the clinician responsible.

Other operations Other operations and important procedures carried out should also be listed.Remember:

to differentiate between open and endoscopic•procedureswhere scopes are used identify the type: rigid or flexible•to state the specific site and laterality of the operation•

The immediate discharge document should follow the guidelines issued by SIGN (Scottish Intercollegiate Guidelines Network).

high quality national data for audit, outcomes, research and management depends on clinicians

national health information the doctor’s role

A POCKet GUIDe fOR MeDICAl StAff