Recheck Examinations and Results

1. Recheck Examinations and Results Of course it’s hard. That’s what makes it difficult.

2. A recheck is a PROCEDURE with: • Implied content • Physical examination • History • Implied context or focus • Previous diagnosis or procedure • An outcome • Findings/assessments

3. 1. Code the procedure Existing concept captures procedure and implied context: History and physical examination, follow-up (procedure) 113009005

4. Code the context: Post-coordinate object of the recheck using “Has focus” attribute: History and physical examination, follow-up Has focus Diabetes mellitus History and physical examination, follow-up Has focus Ovariohysterectomy

5. Coding recheck “diagnoses” Post-operative state (finding) has been suggested ISA Post-procedural state finding Interprets General clinical state • No equivalent term to use for rechecks of disorders • Vacuous unless further specified • NOT a diagnosis or finding in itself • NOT an appropriate medical record entry in itself!

6. Post-operative state, specified? Option 1: • Add subtypes to Post-operative state: • Post-operative state—satisfactory • Post-operative state—unsatisfactory • Enter appropriate subtype in EMR

7. Option 1 PRO • Simple • Allows searching by outcome CON • Limited expressivity • How to specify nature of “unsatisfactory”? • How to link outcome to specific procedure?

8. Post-operative state, specified? Option 2a: Post-coordinate using Has interpretation: Post-operative state (finding) ISA Post-procedural state finding Interprets General clinical state Has interpretation: [ ……..] ?

9. Option 2a/2b PRO: • May be sanctioned by SNOMED • Potential expressivity CON: • How to link outcome to specific procedure? • Appropriate values for “Has interpretation” not yet defined

10. Problems with “Has interpretation” • Allowed values not yet determined • Interpretation of “normal” not simple: • No abnormality present vs No abnormality detected • “Normal” post-op status not necessarily = “no abnormality” • May not allow specific abnormal findings eg “infection” or “poor wound healing.”

11. Other options for coding outcomes: Use General body state finding: • Progress satisfactory • Patient's condition deteriorating • Patient's condition poor • Patient's condition the same • Patient's condition unstable

12. General body state finding PRO: • “Progress satisfactory” acceptable as “diagnosis” • Allows searching by outcome CON: Less clear how to code negative outcomes • No generic “Progress unsatisfactory” • How to specify exact nature of problem? • How to link specific abnormality to “outcome” finding?

13. Also previously proposed: Complications of surgical procedure PRO: • Can link to specific procedure by using Temporally follows Procedure X CON: • No equivalent term for all disorders • Not clear how to specify nature of complication

14. Specifying nature of abnormal findings: Post-coordinate Associated morphology to one of proposed “outcome” findings? PRO: Potential expressivity CON: No sanctioned and tested approach to this Doesn’t work for infection—big problem

15. Infection is not a morphology Cannot specify “infection” by post-coordinating existing morphologies like Purulent discharge (morphology) Such constructions will not be found by searches for “infection” nor are all infections characterized by purulent discharges

16. I am the great and powerful SNOMED…. • Ignore the man behind the curtain • Balloon not fully inflated • Cannot find Kansas • May not take Toto • Knots tied by previous owner of balloon cannot be untied

17. So what DO we recommend? A conservative approach, recognizing: • That it is more vital NOT to say anything false than to say everything that is true • That current realities of SNOMED and medical records systems limit expressivity

18. Code the recheck procedure History and physical examination, follow-up Has focus [diagnosis or procedure being rechecked] Specifies: • That this is a recheck • Object of recheck

19. Code the findings of the recheck • If patient doing well, use Progress satisfactory • If patient has a problem, enter most appropriate diagnosis, such as Post-operative wound infection Non-union of fracture • Can post-coordinate a finding site to further specify the diagnosis

20. Bottom line: We CANNOT currently recommend any construction that would link the recheck procedure to specific findings or outcomes.

21. WHY NOT? • SNOMED does not support or sanction this level of granularity • None of proposed approaches have been tested • Retrieval of information so coded cannot be guaranteed

22. Example 1 Recheck of surgical procedure to correct anterior cruciate ligament rupture, healing well, suture removal

23. Example 1 Code the two procedures: Suture removal History and physical examination, follow-up Has focus [specific procedure used] Code the “diagnosis”: Progress satisfactory

24. Example 2 Recheck mandibular fracture, fracture repair site infected with purulent discharge

25. Example 2 Code the recheck procedure: History and physical examination, follow-up Has focus [specific procedure used] Code the “Diagnosis”: Post-operative wound infection Note: not important to code the discharge as it is only a symptom of the infection, which has been captured

26. Example 3: Dog hit by car, had hip replacement for shattered femoral head and also splenectomy for ruptured spleen Hip replacement doing well but abdominal incision has dehisced.

27. Example 3 Code the recheck procedure: History and physical examination, follow-up Has focus Splenectomy Has focus Replacement of femoral head by prosthesis

28. Example 3 cont’d Code the “diagnosis”: Wound dehiscence Finding site Abdominal wall (in this case, specify finding site to clarify which surgical wound dehisced)

29. Example 4 Cat rechecked for abscessed bite wound on face, treated medically with antibiotics and hot compressing at home. Abscess resolving, but cat now has a new abscess on tail.

30. Example 4 Code the recheck procedure: History and physical examination, follow-up Has focus Abscess of face (disorder) Code diagnosis: Abscess (disorder) Finding site Tail In this case, need to specify finding sites to distinguish between old and new abscess