Recheck Examinations and Results

Of course it’s hard. That’s what makes it difficult.

A recheck is a PROCEDURE with:

Implied content Physical examination History

Implied context or focus Previous diagnosis or procedure

An outcome Findings/assessments

1. Code the procedure

Existing concept captures procedure and implied context:

History and physical examination, follow-up (procedure) 113009005

Code the context:

Post-coordinate object of the recheck using “Has focus” attribute:

History and physical examination, follow-upHas focus Diabetes mellitus

History and physical examination, follow-upHas focus Ovariohysterectomy

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!

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

Option 1

PRO Simple Allows searching by outcome

CON Limited expressivity How to specify nature of “unsatisfactory”? How to link outcome to specific procedure?

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: [ ……..] ?

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

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.”

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

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?

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

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 thisDoesn’t work for infection—big problem

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

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

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

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

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 infectionNon-union of fracture

Can post-coordinate a finding site to further specify the diagnosis

Bottom line:

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

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

Example 1

Recheck of surgical procedure to correct anterior cruciate ligament rupture, healing well, suture removal

Example 1

Code the two procedures:

Suture removal

History and physical examination, follow-up

Has focus [specific procedure used]

Code the “diagnosis”:

Progress satisfactory

Example 2

Recheck mandibular fracture, fracture repair site infected with purulent discharge

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

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.

Example 3

Code the recheck procedure:

History and physical examination, follow-up

Has focus Splenectomy

Has focus Replacement of femoral head by prosthesis

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)

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.

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