Why don’t we code everything in a medical letter?

When coding a medical letter, it’s easy to fall into the trap of recording every detail, making it challenging to distinguish relevant information from unnecessary data. However, selective coding helps prioritize clinically meaningful details, ensuring that the recorded data supports patient care and administrative needs without overwhelming the recipient.

Proper coding will avoid information overload (for everyone!)

Over-coding a letter can create a very complicated, difficult-to-understand final result. For example, if you are coding a letter regarding a patient who has fractured his or her right leg, you may read in the letter that the patient had a cold while attending the appointment. This observation is seemingly unrelated to the diagnosis of a leg fracture, and therefore does not need to be coded in the letter.  

If you decide to code a cold, rather than focusing on the fracture, the purpose of the letter may get lost and the individual(s) on the receiving end may feel there is too much unrelated information recorded. It will also overload your own process, as you may feel you need to code more and more as you code future letters. It’s very important to use your judgement to code what you believe is relevant and important, and leave the rest.

Capturing Meaningful & Actionable Data

There may be certain things mentioned in a letter that is medically relevant about the patient. For example, if the same patient who has fractured his or her right leg, has a history of fractures, this would be relevant information to include in your coding.  

You want to make sure that any data that has meaning or is actionable, is included. In order to do this, you must apply a certain level of critical thinking while coding to make good judgement calls regarding the information shared. It’s also very important to try to read the letter fully to gain an understanding of the situation in the letter as a whole. This will help you make better decisions, recognise meaningful data, and become a better coder.

What happens if you’re unsure if something mentioned in the letter is relevant?

There will be times where it is difficult to decide if something is medically relevant or not to code. If you are unsure and do not want to exclude something, in fear that it may be important, you can enter it into the ‘All Other Useful Information Table’. This way, the receiving party can decide whether or not the information is relevant and handle it how they would like to.

Making decisions when coding can be tricky at times. It’s important to remember that over time your decision-making skills regarding clinical coding will improve as you gain more experience and knowledge around the type of information involved.