recheck examinations and results
DESCRIPTION
Recheck Examinations and Results. Of course it’s hard. That’s what makes it difficult. A recheck is a PROCEDURE with:. Implied content Physical examination History Implied context or focus Previous diagnosis or procedure An outcome Findings/assessments. 1. Code the procedure. - PowerPoint PPT PresentationTRANSCRIPT
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Recheck Examinations and Results
Of course it’s hard. That’s what makes it difficult.
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A recheck is a PROCEDURE with:
Implied content Physical examination History
Implied context or focus Previous diagnosis or procedure
An outcome Findings/assessments
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1. Code the procedure
Existing concept captures procedure and implied context:
History and physical examination, follow-up (procedure) 113009005
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Code the context:
Post-coordinate object of the recheck using “Has focus” attribute:
History and physical examination, follow-upHas focus Diabetes mellitus
History and physical examination, follow-upHas focus Ovariohysterectomy
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Coding recheck “diagnoses”
Post-operative state (finding) has been suggested
ISA Post-procedural state finding
Interprets General clinical state
No equivalent term to use for rechecks of disorders Vacuous unless further specified NOT a diagnosis or finding in itself NOT an appropriate medical record entry in itself!
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Post-operative state, specified?
Option 1:
Add subtypes to Post-operative state: Post-operative state—satisfactory Post-operative state—unsatisfactory
Enter appropriate subtype in EMR
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Option 1
PRO Simple Allows searching by outcome
CON Limited expressivity How to specify nature of “unsatisfactory”? How to link outcome to specific procedure?
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Post-operative state, specified?
Option 2a:
Post-coordinate using Has interpretation:Post-operative state (finding)
ISA Post-procedural state finding
Interprets General clinical state
Has interpretation: [ ……..] ?
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Option 2a/2b
PRO: May be sanctioned by SNOMED Potential expressivity
CON: How to link outcome to specific procedure? Appropriate values for “Has interpretation” not yet
defined
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Problems with “Has interpretation”
Allowed values not yet determined Interpretation of “normal” not simple:
No abnormality present vs No abnormality detected “Normal” post-op status not necessarily = “no abnormality”
May not allow specific abnormal findings eg
“infection” or “poor wound healing.”
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Other options for coding outcomes:
Use General body state finding:
Progress satisfactory Patient's condition deteriorating Patient's condition poor Patient's condition the same Patient's condition unstable
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General body state finding
PRO: “Progress satisfactory” acceptable as “diagnosis” Allows searching by outcome
CON:Less clear how to code negative outcomes
No generic “Progress unsatisfactory” How to specify exact nature of problem? How to link specific abnormality to “outcome” finding?
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Also previously proposed:
Complications of surgical procedure
PRO: Can link to specific procedure by using
Temporally follows Procedure X
CON: No equivalent term for all disorders Not clear how to specify nature of complication
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Specifying nature of abnormal findings:
Post-coordinate Associated morphology to one of proposed “outcome” findings?
PRO:Potential expressivity
CON:No sanctioned and tested approach to thisDoesn’t work for infection—big problem
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Infection is not a morphology
Cannot specify “infection” by post-coordinating existing morphologies like
Purulent discharge (morphology)
Such constructions will not be found by searches for “infection” nor are all infections characterized by purulent discharges
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I am the great and powerful SNOMED….
Ignore the man behind the curtain Balloon not fully inflated Cannot find Kansas May not take Toto Knots tied by previous owner of balloon
cannot be untied
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So what DO we recommend?
A conservative approach, recognizing:
That it is more vital NOT to say anything false than to say everything that is true
That current realities of SNOMED and medical records systems limit expressivity
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Code the recheck procedure
History and physical examination, follow-up Has focus [diagnosis or procedure being rechecked]
Specifies: That this is a recheck Object of recheck
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Code the findings of the recheck
If patient doing well, use Progress satisfactory
If patient has a problem, enter most appropriate diagnosis, such as Post-operative wound infectionNon-union of fracture
Can post-coordinate a finding site to further specify the diagnosis
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Bottom line:
We CANNOT currently recommend any construction that would link the recheck procedure to specific findings or outcomes.
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WHY NOT?
SNOMED does not support or sanction this level of granularity
None of proposed approaches have been tested
Retrieval of information so coded cannot be guaranteed
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Example 1
Recheck of surgical procedure to correct anterior cruciate ligament rupture, healing well, suture removal
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Example 1
Code the two procedures:
Suture removal
History and physical examination, follow-up
Has focus [specific procedure used]
Code the “diagnosis”:
Progress satisfactory
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Example 2
Recheck mandibular fracture, fracture repair site infected with purulent discharge
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Example 2
Code the recheck procedure: History and physical examination, follow-up
Has focus [specific procedure used]
Code the “Diagnosis”:Post-operative wound infection
Note: not important to code the discharge as it is only a symptom of the infection, which has been captured
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Example 3:
Dog hit by car, had hip replacement for shattered femoral head and also splenectomy for ruptured spleen
Hip replacement doing well but abdominal incision has dehisced.
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Example 3
Code the recheck procedure:
History and physical examination, follow-up
Has focus Splenectomy
Has focus Replacement of femoral head by prosthesis
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Example 3 cont’d
Code the “diagnosis”:
Wound dehiscence
Finding site Abdominal wall
(in this case, specify finding site to clarify which surgical wound dehisced)
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Example 4
Cat rechecked for abscessed bite wound on face, treated medically with antibiotics and hot compressing at home. Abscess resolving, but cat now has a new abscess on tail.
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Example 4
Code the recheck procedure: History and physical examination, follow-up
Has focus Abscess of face (disorder)
Code diagnosis:Abscess (disorder)
Finding site Tail
In this case, need to specify finding sites to distinguish between old and new abscess