> ## Documentation Index
> Fetch the complete documentation index at: https://docs.phbhealth.com/llms.txt
> Use this file to discover all available pages before exploring further.

# How clinical coding works

> What PHB records as free text, what it records as a code today, and what is not available yet.

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](/care/lab/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](/reference/glossary).


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