Completion of the Episode – Diagnoses Tab
Before you begin
Once the billing cycle has been completed, either one of two things may happen; a Medical Coder may come to the facility and code the various medical procedures entered into Day Surgery by the staff for reporting purposes, or the coder may code the procedures and enter them into the Day Surgery module themselves.
From within the patient's record:
Procedure
- Within Bluechip, open the patient's record.
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Within the Patient Explorer, press F8 or click
The Day Surgery module will open in MS Access, and you will be prompted to create a new episode. -
Click
at the prompt. The window appears.
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Enter search criteria as desired, to find the patient's episode, and then click
- The patient's episode will be displayed. If there is more than a single episode associated with the patient, ensure the correct episode is being displayed.
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Select the Diagnoses tab.
- Use the Principal Diagnosis drop-down list to select a code, or enter one manually, and then press the [Tab] key. The corresponding description automatically appears in the adjacent field. Using the drop down menu, this can be changed as required. Alternatively, type in the description or use the drop-down list to select and press [Tab]. This will automatically display the code.
- Use the drop-down list to select, or type in the ICD code as defined by the Medical Coder and press [Tab]. This may or may not coincide with the Principal Diagnosis code and description. The Condition Onset Flag is selected if the condition arose whilst admitted to the facility.