Clinical coding (write back)

Modified on Thu, 24 Aug 2023 at 03:55 PM

Note: Clinical system integration is currently only available in England

askmyGP allows clinical codes to be attached to a patient's request and recorded in their clinical record upon completion. There are a few different ways that codes can be added to a request currently.

Forms

The askmyGP team have created an expanding repository of forms for you to select and send through to patients for completion. With write back in place, we now have the ability to assign SNOMED codes to the forms within askmyGP and have these appear in the patient record at the point of completion. An example might be coding the calculated GAD-7 score after a patient has completed the relevant form.

All of the coding for forms is handled by the askmyGP team, we embed the appropriate codes into the forms so that these are automatically written back along with the rest of the request history at completion.

To do this, the form would be completed as below by either the patient, or the practice on their behalf for telephone requests:

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Then, when the request is completed, any attached codes will appear on-screen, and will be written back to the clinical system when you select 'Copy to record system':

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If for any reason you did not wish for a code to be written back, you can simply click the 'Remove' option next to the code before selecting 'Copy to record system'

(for more general information on forms, please see this article)

Preset Messages

Another mechanism for codes to be added to a request is via 'Preset Messages'. For preset messages, the coding is all managed by the Practice, you can create a new Preset Message by going to 'Settings', then 'Preset Messages' and following the steps on this article.

You can add a code to an existing Preset Message by editing it, or to a new one on the Preset Message creation screen. In both cases, you would begin entering the 'Code term' in the 'Search' field, as illustrated in the example below for 'Smoking cessation advice':


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Doing so will return relevant codes which contain the code term you have entered:

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Once you have selected the code you need, you can click the mceclip3.png button in the bottom left-hand corner to save the Preset Message. If you wish to add multiple codes to a single Preset Message, you can select the 'Add code' button beneath the code you just added, and repeat the steps above.

With this in place, each time this Preset Message is sent to the patient, askmyGP will automatically be adding that SNOMED code to their record at the point of request completion.

Ad-hoc Coding

Codes may also be added ad-hoc from the message thread and to requests at the point of filing at completion, when setting it to wait, or when transferring it within a network. The coding interface remains similar in each case:

  • To add a code when viewing a request, click the 'Edit codes' icon:
    mceclip4.pngAnd then select 'Add code':

    mceclip6.pngFind the relevant code using the 'Search' field, select it and then click 'OK' to save it to the request:
    mceclip5.png
  •  Adding codes at the point of completion/wait/transfer, works in a very similar way. The copy dialogue boxes all present the ‘Add code’ option so you would simply click that:
    mceclip6.png

     

    You would then follow the steps above to search for your code(s) and then click the 'Copy to record system' button to save the codes and initiate writeback for the request.

    Code validation:

    Clinical systems differ in their management of code validation, with potentially adverse consequences. Care is needed to ensure a valid match between selected codes and those available within your clinical system.

    In EMIS, the record system will treat any incorrect filings (i.e. unmatched codes) as if they were valid codes, but these codes will not be searchable within the record (since they do not
    appear on the inbuilt lists).

     

    In TPP, the filing attempt will fail if the codes do not match.

    Invalid codes, or any that are not required, may be removed from the filing using the ‘Remove’ button shown in the copy dialogue box.

    mceclip7.png