Hospitals and practices deal with an immense amount of patient data on a daily basis. Clinical coding allows that information to be translated accurately into categorised coded data that can then be used to ensure that the hospital is correctly reimbursed for treatments. Coding in healthcare also makes it possible for management, analysts and others to monitor the provision of services, discover health and care trends and plan services accordingly.
Moving from ICD-10 to SNOMED CT
Computer-assisted coding (CAC) and medical coding products meanwhile have made it possible to code faster, in higher volumes and with greater complexity than before.
Accurate coding across many medical disciplines requires the use of complex clinical vocabularies that are standardised between multiple systems.
For more than two decades the ICD-10 clinical vocabulary has been in use by the NHS, and by many other global healthcare services.
But from April 2018 a new, more precise vocabulary tailored for use in electronic patient records is being implemented in the UK – SNOMED CT.
SNOMED contains more than 300,000 medical terms, enabling finely pinpointed coding, but this in turn means that notes recorded by medical staff must be precise.
Fortunately, Dragon Medical solutions offer an accurate speech-to-text speech interface that enables clinicians to rapidly record rich patient narratives and treatment details.
This will make it easier for clinical coders to code treatments accurately using the full breadth of the SNOMED CT vocabulary.
Tackle the challenges of clinical documentation and coding
Dragon Medical’s advanced speech-to-text capabilities allow clinicians to simply speak directly into the electronic patient record. This means records can be more detailed and accurate – providing clinical coders with richer detail upon which to determine the coding reducing the need to seek clarification from clinicians and saving time.
This improves:
• Accuracy of patient documentation
• Completeness of medical records
• Time and resources spent on clinical documentation
A study conducted by Nuance into clinical documentation shows that in 27.4% of medical records, information was not available or had insufficient detail, whilst documentation accounted for 50% or more of a doctor’s time
