Completion of the Episode - Procedures
The Procedures tab allows entry of the procedures actually performed by the Day Surgery to be used for reporting purposes to the relevant governing body.
Before you begin
About this task
Procedure
- Enter in the Principal Procedure code. This is a mandatory field. This can be directly typed into the field or found by using the associated drop-down list. The code is provided by the Doctor or Coder. The 2 numerals after the code indicate slight variations to the procedure performed.
- Press [Tab]. The code's description will appear next to the code. The date is prepopulated. The Location defaults to the Day Surgery (this facility).
- Enter in the ICD code. The ICD code is derived by the Medical Coder. This may or may not be the same as the Principal Procedure. Press [Tab] to enter the code's associated description automatically. The location defaults to 'This facility'. This can be changed in the event that any secondary procedure associated with or arising from the principal procedure needed to be performed elsewhere.
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Enter in any secondary ICD codes as provided. If an extra secondary procedure is entered by mistake, click the
button to remove it. - Enter the Diagnostic Related Group (DRG) if applicable.
- Change the DRG version if required.
- Click the Completed button. This automatically presents the Notes tab which is discussed following.