PAS Outpatients - Recording Diagnosis Codes and Recording Procedure codes with a Diagnosis Code

Recording Diagnosis Codes and Recording Procedure codes with a Diagnosis Code

From the OP BASIC MENU select RECORD OUTCOME (HOOA) and enter the patient number or details. Check you have the correct patient and enter A to Accept.

Attended? - Enter Y or N depending on whether the patient attended.

Care Stage* - This field may be pre-filled. F1 will display a code list.

Reason for Referral* - This field may be pre-filled. F1 will display a code list.

Outcome - Enter the code indicated on the outcome form. F1 will display a code list.

Time of Arrival - May be entered here if not previously entered.

Time seen - Enter if required.

Grade of Staff - Enter the code for the appropriate person who reviewed the patient. F1 will display a code list.

If no procedure has been performed A to accept.

To enter a diagnostic code, enter O (Other) and enter DC

Free text the diagnosis code into the first field and return. Multiple entries can be made.

Once the diagnosis codes have been entered return through the fields.

Coding complete Y

A to Accept and enter the RTT code

If the outcome was Further Appointment or Add to Follow-up Pending List, you will be taken to the next screen

* If a procedure has also been performed during the outpatient attendance this must be recorded in addition to the Diagnosis Codes The codes MUST be entered in the order they appear on the outcome form

At Care stage, enter 2 for Treatment, and Reason for referral, enter 2 for a specific Procedure.

Once entered the letters PC will populate the bottom right data field.

If a procedure has been performed, return over PC and enter the code indicated on the outcome form.

Once all the codes have been entered return to Coding complete and Enter Y for Yes.

A to accept the procedure codes. You will then be returned to the outcome screen.

Select O (Other)

Enter DC

Free text the diagnosis code into the first field and return. Multiple entries can be made.

Once the diagnosis codes have been entered return through the fields.

Coding complete Y

A to Accept and enter the RTT code

If the outcome was Further Appointment or Add to Follow-up Pending List, you will be taken to the next screen