Background
An acute coronary syndrome care pathway pro-forma has been introduced to be completed by clinicians to aid the coding of co-morbidities.
Objective
To identify any clinical risk factors that will aid the clinical coder when recording co-morbidities.
Outline
The care pathway document was produced by clinicians and other healthcare staff and includes a list which identifies factors, such as hypertension, diabetes, hyperlipidaemia, ischaemic heart disease, smoking and family history, that are considered relevant to the primary diagnosis. This documentation is completed by clinicians and nursing staff and then added to the patient case note.
Impact
Clinical coders have a clearly documented form highlighting relevant co-morbidities. The Trust has also developed a similar process for the deep vein thrombosis care pathway.
Source: D&A Consultancy Ltd and Western Sussex Hospitals NHS Trust