Coding of Diagnoses and Therapies Organisation of Clinical Documentation Workflow Processing of Patient Information Training of Other Occupational Groups
Diagnosis and treatment (surgical procedures) of every patient have to be coded using the ICD 10 code, respectively the OPS classifications. The documentation of medical cases has to be processed in such a way that a coherence between diagnosis and therapy, as well as between the state-of-the-art in medicine and patient care can be reconstructed.
Within this workflow, we take an influence on the processing of data by designing on-screen- and paper-forms. Through diligent management of patient records during in-patient care, we provide the organisational support of the care process. By making use of our special skills, we support the transition from paper-based records to electronic patient records, as well as running archives for paper-based patient records.
In central administrative units, either in clinical departments or directly on the wards, we extract all relevant information from the patient records. We code diagnoses and procedures based on official classifications (ICD10, OPS). On the basis of the primary documentation, we verify already coded data, revise it if necessary and confer with the treating physicians. Finally, we group the collected DRG-data for revenue calculation by using specially designed software. Together with the physicians, we also discuss revision cases handed in by the Medical Control Service of the German health insurance companies (MDK, Medizinischer Dienst der Krankenkassen).
Given the high relevance of medical documentation and continuously changing legal requirements, we develop internal coding guidelines and figure as contact persons regarding all questions on correct documentation and classification. We provide training material and perform training programs for physicians, nurse staff and senior house officers/ residents.
Coding of Diagnoses and Therapies
Organisation of Clinical Documentation Workflow
Processing of Patient Information
Training of Other Occupational Groups