How to Update Uncoded Past Medical History Items

Before you begin

MedicalDirector provides a simple utility in MedicalDirector Maintenance that enables you to easily find non-coded Past Medical History items, and either link them to a coded item or replace them with the correct coded item.

Procedure

  1. Double click the MedicalDirector Maintenance icon to open MedicalDirector Maintenance.
  2. Select Clinical in the list of Database Tasks on the left of the window.
  3. Double click the Diagnosis > Coder icon.



    • The left-hand panel of this screen contains all the uncoded diagnosis entries in the Past Medical History database. The right-hand panel displays coded entries that you will select from to pair-up with your uncoded entries. Note that the right-hand panel is initially empty, but as you type into the text box above it (in this example appen), a list of items is generated underneath
    • Simply highlight the entry on the left and the one you want to link or replace it with on the right, and then click either the Link or Correct button
    • The Link button will attach the code for that diagnosis to the coded entry on the right
    • The Correct button will change the diagnosis on the left to that on the right i.e. if the word was misspelled
    • Once you have worked your way through all the uncoded diagnosis occurrences, all uncoded items will be replaced and coded, and therefore allow the now coded data to be included when conducting a search.

Results