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Clinic Coding New Concepts in Ingenuity

Clinic Coding New Concepts in Ingenuity. Prepared by Donna Thompson Supervisor Health Information Services Joseph Brant Memorial Hospital. The Mandate.

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Clinic Coding New Concepts in Ingenuity

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  1. Clinic CodingNew Concepts in Ingenuity Prepared by Donna Thompson Supervisor Health Information Services Joseph Brant Memorial Hospital

  2. The Mandate • Nov. 8, 2001 letter from MOHLTC mandated the reporting of SDC, April 1, 2003, and stated they would examine feasibility of reporting certain high cost medical daycare procedures • Reporting of dialysis, oncology and cardiac catheterization medical daycare and clinics deferred until October 1, 2003

  3. The Process • ACTRF meetings conducted • Discussion and interpretation of data elements • CIHI and Ministry available for assistance • Discussion and support from peer hospitals

  4. What Do We Need to Do? Code Oncology Clinic Activity Be creative in the use of existing resources to successfully meet the mandate

  5. Our Data Structures Challenges • Data Sources • Opis • Meditech Clinic Registrations • Abstracting Software • Winrecs • Workload • Volume 550 records per month

  6. The Process • Informal meeting with Peer Hospitals and CCO • Discussion of process – the real work flow • Discussion of what codes to be used • Discussion on CIHI coding queries • Follow up questions raised

  7. The Process • Data captured and registered in Opis: Patient demographics Initial working Diagnosis – I10 & I9 Interventions completed Retrospective coding Customization of OPIS Reports • Data Captured in Meditech: By Functional Centre Location Code with diagnosis & Procedure

  8. The Customization Of Reports • Create Customized report for Chemo and Clinic Visits • Data already captured in OPIS prints on report used for coding • Customized report created for visits in Meditech • Data prints interventions performed

  9. Patients registered in OPIS or Meditech Oncology Clinic Visits Decision Making Data Housed in respective system Funding Data Cycle Customized Reports Printed Data Submission Time lines Adaptation of Software for submission Submission To CIHI Analysis & Coding

  10. Customization of Winrecs

  11. Customization Of Winrecs • Create Profiles - Same information applied across many different patients eg Same Clinic type of visit different patients - Cloning of abstracts – the same patient returning for many visits of the same nature. E.g. chemotherapy

  12. Crunching of The Numbers • 550 visits to be recorded • Visits abstracted retrospectively • 15 hours per week allocated to the process

  13. Our Strategies For Success: “Customization” • Maximize the resources you have available • Use staffing resources effectively -Optimize software to create efficiencies -Continually tweak the process

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