Benefit Stories

EPR will crack the code of more accurate information

Clinical coding teams are amongst the unsung heroes of the NHS, and with the advent of EPR, the working day of a clinical coder could look quite different to how it does today.

Clinical coders take medical records and convert the information into codes that the NHS then uses to monitor targets and reimburse Trusts for the treatment and care patients receive.  Without their work, the crucial decision-making of clinicians cannot be quantified and NHS Trusts may not receive the right money from the government.

It’s not an easy task.  Clinical coders are like detectives – finding information buried in clinical notes, interpreting it and converting it into the magical alpha-numeric codes that allow activity to be reported.   The typical day of a coder may involve tracking down the hand-written notes of patients who were discharged, reading through reams of paper to find the crucial information that allows them to code and chasing up missing detail.  

EPR could transform this process.  Firstly, it will improve how lists of discharged patients are handled. Dependency on paper notes will also reduce, and coders will be able access a patient’s records without hunting for hard copies.   

Interpreting people’s handwriting could also be a thing of the past as records are typed, and the clever way in which EPR records information - through a series of pre-defined forms, drop-down lists and mandatory fields means that the information coders need is more likely to be available. The diagnosis and problems list in EPR uses a structured language called SNOMED which will eliminate mis-spelling and reduce the confusion from using imprecise terms and abbreviations.

“EPR will improve the quality and accuracy of our work as coders,” says Janet Crabtree, from the BTHFT coding team."

Sharan Boothroyd, from CHFT coding team adds “This is a great opportunity to ensure that the coders are presented with detailed level of specificity and that the patient record can be accurately populated. Building familiarity with the system for coders and clinicians will be essential from the onset.”

In summary:  EPR benefits for clinical coding

  • Electronic patient records will ensure that all of the information is recorded in one place and is easily accessible without having to hunt for paper notes

  • Writing will be legible, avoiding the need to follow up with clinicians for clarification

  • Pre-defined forms and drop-down lists in EPR will support thorough, consistent record-keeping

  • Diagnosis and problems will be recorded using SNOMED codes which will make clinical notes more precise and easier to analyse

  • More accurate coding means that Trusts can report accurately and as a result receive the correct money for the care they offer patients.