How clinical coding works

Today PHB is mostly free text. Clinicians write what they find in their own words. Codes are used in a few places only.

What is live

Where	What is stored
Encounter note	Free-text SOAP note. The Assessment is written in words, not chosen from a code list.
Patient conditions	A name (required, up to 160 characters) and an optional ICD-11 code (up to 32 characters). Nothing checks that the code exists.
Vitals	Each vital is stored with its LOINC code.
Lab tests	Each test in a lab’s catalogue is stored with its LOINC code.
Record export	A condition with an ICD-11 code is exported to other systems under the WHO ICD-11 system. A condition without one is exported as text only.

Conditions

A patient adds a condition from Records (ICD-11 code (optional)). It is saved as unconfirmed until a clinician confirms it. There is no screen yet where a clinician adds a coded condition. Conditions also have a field reserved for a SNOMED CT code. No screen or API writes it today.

Encounters

The Dx tab in an encounter is not built on the live system. It is shown disabled. The encounter accepts a free-text note and disposition only. If a request carries coded diagnosis, plan, prescription or lab-order fields, it is rejected. Write the diagnosis in your note.

Sensitive results

Some results and conditions are recognised by their code and held back. Results of certain kinds are not shown to the patient until their doctor releases them. See Sensitive results and release.

Not yet available

Coding standards beyond the ICD-11 field are not built. That includes ICD-10, a code picker and dual coding.

Terms

Term	Meaning
ICD	The WHO list of diagnosis codes. PHB accepts an ICD-11 code on a condition.
SNOMED CT	A large clinical vocabulary. PHB does not use it on screen yet.
LOINC	A list of codes for lab tests and vitals. PHB uses it for both.
Triage acuity	Red, yellow or green, chosen by the nurse.

HPN, encounter, treatment basis and break-glass (emergency override) are defined in the Glossary.

​What is live

​Conditions

​Encounters

​Sensitive results

​Not yet available

​Terms