Medical Coding and Documentation-AI-driven medical coding support

Example

A physician notes that a patient presents with chest pain, elevated blood pressure, and shortness of breath. Medical Coding and Documentation would enhance this clinical summary by structuring it into distinct sections: symptoms, physical examination findings, investigation results, patient education, and diagnosis. It will also suggest the appropriate ICD-10 codes, like I20.0 for 'Unstable angina' and I10 for 'Essential (primary) hypertension.'

Scenario

In a busy emergency department, a physician needs to quickly and accurately document a patient’s condition. The service helps by organizing the documentation, ensuring all relevant information is captured and coded correctly, improving the efficiency and accuracy of patient records.

Example

After a patient’s hospital stay for pneumonia, the physician uses the service to draft a discharge summary. The service structures the summary with clear sections: reason for admission, hospital course, discharge medications, follow-up instructions, and final diagnosis with the correct ICD-10 codes, such as J18.9 for 'Pneumonia, unspecified organism.'

Scenario

A hospital discharge coordinator is responsible for ensuring that every patient leaves with a complete and accurate discharge summary. The service helps by providing a template that includes all necessary sections, ensuring no details are missed, and that the summary is coded properly.

Example

A patient is diagnosed with type 2 diabetes and needs a letter explaining their condition, treatment plan, and lifestyle recommendations. The service drafts a letter free from medical jargon, explaining in simple terms what diabetes is, how it can be managed, and what steps the patient should take, also including an ICD-10 code like E11 for 'Type 2 diabetes mellitus.'

Scenario

A general practitioner needs to communicate a complex diagnosis to a patient in a way that is easily understandable. The service provides a clear, concise letter that breaks down the diagnosis and next steps, ensuring the patient is well-informed and engaged in their care.