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Training Workbook SimpleCode

Version 3.5

Document Version: 1.1

Author: A.H.

Release Date: January 2015

Woodward

Health Information Systems

A S S O C I A T E S

No part of this document may be reproduced, stored in a

retrieval system or transmitted in any form or by any means,

electronic, mechanical, photocopying, recording or

otherwise, without prior written permission of the copyright

holder.

All copyrights are acknowledged.

Body Illustrations Copyright © 2015 Nucleus Medical Media,

All rights reserved.

www.nucleusinc.com

The information in this document is subject to change

without notice. Woodward Associates (UK) Ltd. does not

warrant that this document is error-free.

http://www.nucleusinc.com/

Contents

1 SIMPLECODE ENTRY AND EXIT TECHNIQUES ............................................................................... 7

1.1.1 Entering SimpleCode from your PAS ................................................................................ 7 1.1.2 PAS-to-SimpleCode general restrictions ......................................................................... 7

2 MANAGING EPISODE CHANGES AND EXITING SIMPLECODE .................................................. 8

2.1.1 Save changes and exit SimpleCode .............................................................................. 8` 2.1.2 Ignore changes and exit SimpleCode ............................................................................ 9 2.1.1 Another way to Exit SimpleCode ..................................................................................... 9 2.1.2 Once back in your PAS . . . ................................................................................................ 9

3 SIMPLECODE DEFAULT DISPLAY LAYOUTS ................................................................................. 10

3.1.1 The purpose behind Display Layouts ............................................................................. 10 3.1.2 Simple Layout ..................................................................................................................... 11 3.1.3 Standard Layout ................................................................................................................ 12 3.1.4 ‘All’ Layout .......................................................................................................................... 13 3.1.5 SimpleCode Menu Bar Summary ................................................................................... 14 3.1.6 Building your own personal display layouts .................................................................. 15 3.1.7 Building, Modifying and Saving your Personal Layout ............................................... 15 3.1.8 Save your Personal Layout .............................................................................................. 16 3.1.9 Managing your Layouts ................................................................................................... 17

4 BASIC CODING TECHNIQUES..................................................................................................... 17

4.1.1 Coding diagnoses and procedures overview ............................................................. 17 4.1.2 When you already know the diagnosis or procedure code .................................... 18 4.1.3 Type in a diagnosis code directly .................................................................................. 19 4.1.4 Type in a procedure code directly ................................................................................ 19 4.1.5 Hierarchy Keyboard Control ........................................................................................... 19 4.1.6 Supports for Scottish Primary / Subsidiary procedures ............................................... 20 4.1.7 Coding Wizard Support for Scottish Specialties ........................................................... 20 4.1.8 SimpleCode supports up to and including OPCS 4.6 ................................................. 20 4.1.9 Other Procedure related information ........................................................................... 20

4.2 ADD PROCEDURE-DATE INFORMATION ...................................................................................... 21 4.2.1 Add Surgeon related information .................................................................................. 21

4.3 OVERWRITE CODE AND TERM FIELDS (DOUBLE-CLICK) ................................................................. 22 4.3.1 Refresh Notes (single-click) .............................................................................................. 23 4.3.2 Further note on single-clicking ........................................................................................ 23

4.4 RIGHT-CLICK MOUSE FUNCTIONS .............................................................................................. 24 4.5 KEYBOARD SHORTCUTS ............................................................................................................ 25 4.6 REVIEW CODE-NOTES COLOUR-CODE MEANINGS ........................................................................ 26 4.7 QUICK ACCESS TO DATA QUALITY REVIEW (DQR) SPECIAL NOTES ................................................ 27

4.7.1 Coding Clinic Notifications ............................................................................................... 28

4.8 TYPE IN A TERM ........................................................................................................................ 29 4.8.1 Spelling a Term correctly ................................................................................................... 31

4.9 ENTERING MULTIPLE DIAGNOSES AND PROCEDURES ...................................................................... 31 4.10 USING THE “UP” / “DOWN” BUTTONS ........................................................................................ 32 4.11 MANAGING THE NUMBER OF PROCEDURE AND DIAGNOSIS ROWS.................................................. 33 4.12 EDITING AND VIEWING BEYOND THE DISPLAYED AREA ................................................................... 33 4.13 EXPANDING AND CONTRACTING WINDOWS (DRAGGING) ........................................................... 34 4.14 DEFINING UPPER LIMITS TO DIAGNOSES / PROCEDURES PER EPISODE ............................................. 34 4.15 MANAGING MORPHOLOGY CODES........................................................................................... 35 4.16 SETTING NEO-NATAL LEVEL OF CARE INDICATORS ........................................................................ 36 4.17 SCREEN NAVIGATION USING FAST KEYS ...................................................................................... 36

4.18 EPISODE VALIDATION ............................................................................................................... 37 4.18.1 Validation Form Icon......................................................................................................... 38 4.18.2 Exiting Episodes with invalid coding .............................................................................. 39 4.18.3 Empty Episode validation default state ........................................................................ 39 4.18.4 The meaning of red validation ....................................................................................... 40 4.18.5 The meaning of “information icon” within validation ................................................ 40 4.18.6 SimpleCode ICD and OPCS validation rules ................................................................ 41 4.18.7 SimpleCode built in validation rules ............................................................................... 41 4.18.8 SimpleCode validation attributes .................................................................................. 42 4.18.9 Validation: Episode-level attributes ............................................................................... 42

4.19 DISPLAYING EXTENDED PATIENT DETAILS FROM EPISODE ................................................................ 43 4.20 SIMPLECODE STATUS DISPLAY ................................................................................................... 43 4.21 PRINTING AND EMAILING AN EPISODE ........................................................................................ 44

4.21.1 Report Emailing .................................................................................................................. 45 4.22 COMPLETING AN EPISODE ........................................................................................................ 45 4.23 SIMPLECODE HELP FACILITY ...................................................................................................... 46

4.23.1 Single-click “Online Help” option ................................................................................... 46 4.23.2 Single-click “View Log” option ........................................................................................ 46 4.23.3 Single-click “About” option ............................................................................................. 47 4.23.4 SimpleCode Crashes ........................................................................................................ 47

5 VIEWING AND EDITING WHOLE EPISODES ................................................................................ 48

5.1.1 Reordering diagnoses and procedures within an Episode ....................................... 48 5.1.2 Deleting unwanted specific diagnoses / procedures ............................................. 48 5.1.3 “Clear Episode” button .................................................................................................... 48 5.1.4 Zooming in and out ........................................................................................................... 49

6 USING SPELL DETAIL AND PATIENT HISTORY TO AID CODING ................................................. 49

6.1.1 How Spells are recognised .............................................................................................. 49 6.1.2 Using Spell-Episode tabs ................................................................................................... 50 6.1.3 Editing a whole Spell within one SimpleCode session ................................................ 50

6.2 VIEWING PATIENT HISTORY ......................................................................................................... 51 6.2.1 Spells in Patient-History...................................................................................................... 51

6.3 TAKING CODE DETAIL FROM OTHER PATIENT EPISODES ................................................................... 53 6.4 OTHER SPELL LEVEL FEATURES .................................................................................................... 54

6.4.1 Spell information adding / editing admission notes ................................................... 54 6.4.2 Spell validation information ............................................................................................. 55

7 USING SIMPLECODE TERMS MORE EFFECTIVELY ....................................................................... 56

7.1.1 SimpleCode returns too much Information .................................................................. 56 7.1.2 SimpleCode returns no or little Information .................................................................. 56

7.2 MANAGING “DAGGER*” CODES USING THE ALPHABETIC INDEX .................................................. 57 7.3 MANUALLY SETTING “DAGGER *” CODES ................................................................................... 57

8 ACCESSING ALTERNATIVE-INDICES TABS ................................................................................. 58

8.1.1 Commonly available diagnosis indices ........................................................................ 58 8.1.2 Commonly available procedure indices...................................................................... 58 8.1.1 Commonly available morphology indices ................................................................... 58 8.1.2 Lead Term Search ............................................................................................................. 59

8.2 COMMONLY USED ALTERNATIVE-INDICES ................................................................................... 60 8.2.1 Alternative- Index: neoplasm lists .................................................................................. 60 8.2.2 Alternative-Index: external cause lists .......................................................................... 61 8.2.3 Alternative-Index: traffic Accidents .............................................................................. 61 8.2.4 Alternative-Index: Read clinical terms ......................................................................... 61 8.2.5 Alternative-Index: ICD (and Snomed) drugs ............................................................... 62 8.2.6 Alternative-Index: eponyms ........................................................................................... 62

9 USING SIMPLECODE CODING WIZARDS ................................................................................... 63

9.1.1 Introducing the idea behind coding wizards .............................................................. 63 9.1.2 Using coding wizards ........................................................................................................ 63

9.2 INTRODUCING THE WIZARD-PRIMARY-DIAGNOSIS (W-P-D) WINDOW ........................................... 63 9.2.1 Wizard –Primary -Diagnosis window with (or without) a primary diagnosis ............ 64

9.3 INTRODUCING THE WIZARD-SECONDARY-DIAGNOSIS WINDOW .................................................... 65 9.4 INTRODUCING THE WIZARD-PRIMARY-PROCEDURE (W-P-P) WINDOW .......................................... 66

9.4.1 W-P-P window without a primary diagnosis ................................................................. 66 9.4.2 W-P-P window with a primary diagnosis ....................................................................... 66

9.5 WIZARD-SECONDARY-PROCEDURE WINDOW WITH PRIMARY DIAGNOSIS ........................................ 67 9.6 DEFAULT CONSULTANT/ SURGEON FIELDS ................................................................................... 67

10 SIMPLECODE ADVANCED SCREENS .......................................................................................... 68

10.1 WHY A USER LOCAL DICTIONARY FACILITY IS USEFUL TO YOU .......................................................... 68 10.2 HOW TO ACCESS THE LOCAL DICTIONARY .................................................................................. 68

10.2.1 Adding single or strings of 'local' codes ........................................................................ 68 10.2.2 Using the ‘User Dictionary’ ............................................................................................... 69 10.2.3 Add a hyperlink through User Dictionary ...................................................................... 70 10.2.4 Hyperlink through drag and drop .................................................................................. 70 10.2.5 Modify an external Reference (Hyperlink).................................................................... 71 10.2.6 Adding personal notes to ICD and OPCS codes ........................................................ 71

11 CREATING YOUR OWN DISPLAY LAYOUTS ................................................................................ 72

11.1.1 Edit a current display layout to make temporary changes ...................................... 72 11.1.2 Creating a new personalised display layout ............................................................... 73 11.1.3 Permanently saving your new personalised display layout ...................................... 73 11.1.4 Managing your new personalised display layout ....................................................... 74 11.1.5 Use your new personalised display layout .................................................................... 75

12 SIMPLECODE IMAGE LIBRARY (OPTIONAL) ............................................................................... 75

12.1.1 Enable Image Browsing .................................................................................................... 75 12.1.2 Image window ................................................................................................................... 76

12.2 VIEWING IMAGES .................................................................................................................... 77 12.3 IMAGE SEARCH FACILITY .......................................................................................................... 77

12.3.1 Images via Site Procedure Codes .................................................................................. 79 12.4 IMAGES SUPPORT FOR CACHÉ................................................................................................... 79 12.5 IMAGE BROWSER CONTROL ..................................................................................................... 80

Special Note about SimpleCode Version 3

This document is targeted at SimpleCode Version 3 users. Any reference to SimpleCode in

these notes implies the use of Version 3. Occasionally there are references to Version 2 for

helpful comparisons. When this happens, the earlier version is referenced as SimpleCode

Version 2.

About SimpleCode Version 3 releases

Currently, there are several versions of SimpleCode Version 3 used at sites in the UK. The most

recent version is 3.5

Generally speaking; SimpleCode Versions 3.0 to 3.5 are very similar. This training manual is

pitched at Version 3.5

This manual also applies as a general guide to all version of SimpleCode version 3.

Text conventions used throughout this work book

The terms Episode and Spell are treated as proper nouns and are consistently typed with

a leading capital letter.

For Scotland please note the terminology used in this document:

Episode (England) = SMR (Scottish Morbidity Record)

Spell (England) = Episode (Scotland)

The names of SimpleCode windows are consistently presented in the form Window-

Name window. Where the window name is multi part, then hyphens tie the parts

together. For example: Edit-User-Notes window.

The names of SimpleCode layouts are consistently presented in the form "Display-

layout-Name" layout. Where the display layout name is multi-part, then hyphens tie

the parts together. For example: Wizard-with-Search layout.

Single-click when used throughout this document means:

One single-click of the mouse left-hand button

Double-click when used throughout this document means:

Two single-clicks of the mouse left-hand button

The abbreviation PAS is used throughout this document for Patient Administration

System. An example PAS is TRAK

1 SimpleCode ENTRY and EXIT techniques

1.1.1 Entering SimpleCode from your PAS

Usually SimpleCode is entered via your PAS. Currently there are many different PAS systems

available, so the course instructor will show you how to enter and exit SimpleCode using local

practices.

1.1.2 PAS-to-SimpleCode general restrictions

When you enter a SimpleCode session, details for the chosen single Episode are passed from

the PAS to SimpleCode. This allows you to edit / code / change this Episode. You must exit

and re-enter SimpleCode to code another Episode.

In addition to the above chosen Episode, SimpleCode presents details to you from other

Episodes in its Spell, plus patient history, site history and other useful AutoGrouper server

information taken from national sources. You can take directly from these sources to help

you code the chosen Episode.

Patient Administration System (PAS)

View / take details of other patient Episodes in Spell

CHOOSE SINGLE EPISODE TO CODE

Code chosen Episode in a SimpleCode session

View /take details of other Episodes from Patient-History and Predictive-Coding

2 Managing Episode changes and exiting SimpleCode

There are several exit paths from SimpleCode. All exit paths will offer you the opportunity to

save you coding. SimpleCode does not support intermediate saves of (for example) very

large Episode details. A save action always forces you to immediately exit SimpleCode and

return to your PAS.

2.1.1 Save changes and exit SimpleCode

File -> Save tab

OR

Single-click “Save” button on

SimpleCode tool bar

A Complete-Coding confirmation window will appear

Complete the Coding Status and Coding Source fields

Press “OK” button to Exit

Note: if the Episode has validation errors, other windows may appear depending on how

SimpleCode has been configured.

2.1.2 Ignore changes and exit SimpleCode

EITHER

Single-click SimpleCode menu File -> Exit tab

OR

Single-click “Exit Without Saving” button on SimpleCode

tool bar

“Save changes to Episode” window will be displayed

(Choose No to exit without Save, or Yes to Save

Changes)

2.1.1 Another way to Exit SimpleCode

Single-click Window header "X"

2.1.2 Once back in your PAS . . .

You can re-enter SimpleCode with the same Episode that you saved, and review it again to

ensure the changes you made have been recorded, or edit it to make further changes.

Usually you will choose another Episode (perhaps from another patient) from your PAS lists

and then re-enter SimpleCode.

3 SimpleCode Default Display Layouts

SimpleCode has four display layouts for you to code Episodes. These layouts are called:

1. Simple

2. Standard

3. Waiting Lists and Theatres

4. All

Each of the above can be selected by choosing from the Layout-Selection window situated

on the main toolbar.

Note: SimpleCode will recall the display layout that was active when you last exited, and

automatically reinstate it. The current display layout is shown via the scroll list by a blue

highlight. The Layout-Selection window may show blank on entry to SimpleCode - it will then

remain blank until you choose another display layout.

3.1.1 The purpose behind Display Layouts

Each of the four display layouts provides different levels of support to help you when coding

Episodes.

For example, if you already know all the codes in an Episode, then you might prefer to work

with Simple layout. If you frequently need to research terms, or to pay particular attention to

clinical notes, then you might work with the Standard layout. If you require validation to be

displayed then you can select the ‘All’ layout.

Coding-Wizard and Wizard-with-Search layouts provide historic predictive code information

based on consultant activity and previous patient history at your hospital; plus national

standard AutoGrouper server data.

You can easily switch from one display layout to another during coding. SimpleCode

remembers all the detail of your current Episode coding and transfers it to the newly chosen

display layout.

3.1.2 Simple Layout

The Simple layout is intended for coding Episodes where the coder already knows most, if not

all, diagnosis and procedure codes in advance. The number of diagnosis and procedure

lines displayed can be easily adjusted using windows drag techniques.

Simple layout does not include Alternate-Indices tabs, Predictive-Coding or Patient-History

windows but does include Validation and Notes tab / window.

The code grid header colour changes to a darker shade when selected to distinguish which

grid (pane) is active.

Diagnoses display/input window

Layout selection scroll bar

Coding Notes and Validation tabs / windows

Menu bar

Procedure display/input window

Patient History window

Coders’ Notes and Hyperlinks buttons

3.1.3 Standard Layout

In addition to the Simple layout, the Standard layout has Alternative-index tabs, but does not

show Coding-Wizard, Patient-History or Validation windows.

The Standard layout is similar in overall design to SimpleCode Version 2. It may prove useful

for coders who do not want to use SimpleCode Version 3 more advanced features.

Alternative Indices:

Tabular Index

Clinical Terms

Alphabetic Index

Chemotherapy Regimes

Eponyms

Alternative Indices tabs / windows

3.1.4 ‘All’ Layout

The ‘All’ layout has additional Predictive-Coding windows that give coding suggestions

based on current site Episode history and national grouping data.

All such additional data is stored by SimpleCode in its history database.

This layout combines the Coding-Wizard, Alternative Indices and Validation tabs.

This display layout is intended to use all the major coding features of SimpleCode on one

physical screen. It is probably the most useful display layout for experienced coders.

Predictive Coding windows

Patient History

Code details from Patient History

Alternative Indices tabs / windows

Episode Validation

3.1.5 SimpleCode Menu Bar Summary

Expand Patient Information Create / Modify Personalised Layouts

Save, Exit, Print Episode, Email Episode

Increase Font Size (Does NOT apply to the Notes

window)

Clear Current Episode Data

Layout Scroll Bar

3.1.6 Building your own personal display layouts

SimpleCode enables you to create your own personalised display layouts. You can build,

store and change any number of such display layouts for immediate and future use.

Details of personalised display layouts are stored under your user login. So, as long as you use

the same login, you will have access to your own display layouts.

Saved layouts are display within the layouts scroll bar.

3.1.7 Building, Modifying and Saving your Personal Layout

The easiest way to create and save your own personal layout is to select the ‘All’ layout and

modify the panes as required. (You can use any of the pre-defined layouts as a starting

point).

To remove a pane from an existing window layout click the ‘x’ from within the

window pane.

To reinstate a removed window pane, select the appropriate window pane from with

‘View’.

To modify a layout within an existing window display

Click on tab or pane then drag, (hold left mouse button down) to an appropriate position.

Whilst dragging a pane, a red icon is displayed indicating areas that are not

appropriate for that window pane.

Once an appropriate area is found the red icon disappears and you are able to release the

mouse button and position the pane. Once you have modified the SimpleCode Window you

can save your personal layout.

3.1.8 Save your Personal Layout

When you come out of SimpleCode (save an episode / exit), the current layout displayed on

the screen will be saved – if you have created a personal layout prior to saving, it will now be

remembered.

If you wish to name your layout for future selection then you need to:

Select the Save Layout Icon. Enter an appropriate name for your new layout within the Save

Layout pop-up window. Any saved layout will appear for future selection within the layout

scroll window.

Save Layouts Icon

3.1.9 Managing your Layouts

You can remove or rename a personal layout by selecting the ‘Manage Layouts’ icon and

then selecting the appropriate layout, (click on layout name); from the pop-up window.

Select either the Delete or Rename icon from within the pop-up window. After deleting or

renaming a layout, a confirmation window will appear requesting confirmation prior to

modifying or deleting.

4 Basic CODING Techniques

4.1.1 Coding diagnoses and procedures overview

SimpleCode is very easy to use. All the display layouts provide input windows for coding

diagnoses and procedures. Each window has separate columns for codes and descriptions.

You must always be careful to place codes and descriptions correctly.

Manage Layouts Icon

Delete or Rename Icons

Select Layout to Modify

4.1.2 When you already know the diagnosis or procedure code

If you know part or all of a diagnosis or procedure code, then type what you know straight

into the appropriate code box.

After any characters are typed into either of the Code columns of the Diagnosis or

Procedure windows, a Code-Hierarchy window is automatically opened by SimpleCode that

displays targeted classification areas for you based on what you have typed. For example, if

you enter part of a code, then the Code-Hierarchy window supports you by displaying all

possible code extensions with an extra digit.

If you enter a two digit code, then the Code-Hierarchy window displays possible three digits

codes. If you enter a three digit code, then the Code-Hierarchy window displays possible

four digit codes.

You can update the current Code / Description fields in the Diagnosis-Input window by

double-clicking on a chosen code or the description from within the Code-Hierarchy

window.

4.1.3 Type in a diagnosis code directly

Type Diagnosis Code: J or J0 (into any position)

Observe: how Code-Hierarchy window displays

3 - character code groups that match J** or J0*

Type Code: J01

Observe: how Code-Hierarchy window displays

4 - character groups that match J01*

Double-click J011 in the Code - Hierarchy

window

Observe: input area code and term description

are updated.

4.1.4 Type in a procedure code directly

Procedure codes are handled in a similar manner to diagnosis codes. The Code-Hierarchy

window automatically displays targeted procedure classifications based on your input. You

can update the current Code / Description fields in the Procedure window by double-

clicking the mouse on a chosen code or the description from within the Code- Hierarchy

window.

4.1.5 Hierarchy Keyboard Control

When selecting a code from the hierarchy popup window, you can also use the arrow keys

to select a code and press enter to select the code instead of using a mouse.

4.1.6 Supports for Scottish Primary / Subsidiary procedures

SimpleCode can be configured to support Scottish Primary / Subsidiary procedure

classification. If enabled, then procedures can be tagged as primary or subsidiary by single-

clicking on the third field of the Procedure - Input window.

Note: SimpleCode obeys the following primary/subsidiary relationship rules:

Primary must precede a subsidiary

Primary may own only zero (0) or one (1) subsidiary procedure.

Single-click on the primary symbol to flip it to subsidiary and visa versa

4.1.7 Coding Wizard Support for Scottish Specialties

Coding wizard requires a specialty code to search for recommendations but only supports

English codes. Scottish specialty codes are now converted to English equivalents for

recommendations.

4.1.8 SimpleCode supports the latest OPCS 4

Type procedure Code A43

Observe: the Code-Hierarchy window displays OPCS 4.7 A43* codes

4.1.9 Other Procedure related information

Some coding groups require additional procedure-related information, notably, procedure

dates and consultant details. SimpleCode can be configured to allow different sites different

levels of Episode support detail. Note that this information is important to complete for quality

purposes.

4.2 Add Procedure-Date information

Single-click Procedure-Date field

Observe: A procedure date based on admission date is automatically

inserted by SimpleCode

If the inserted date is not suitable then

Single-click: Procedure-Date

Single-click: Field scroll button

Choose Date as required

Observe Chosen date is automatically inserted

4.2.1 Add Surgeon related information

Single-click Staff-Type field

Single-click Staff-Type scroll button

Choose A staff type description from the list

Single-click Surgeon field

Single-click “Surgeon” scroll button

Choose A surgeon name from the list

4.3 Overwrite Code and Term fields (double-click)

Overview

Double-clicking on a displayed code from any SimpleCode window will cause the chosen

code and its term to be written back to the current display position. This is true for both

diagnoses and procedures.

When selecting a code from the hierarchy popup window, you can also use the arrow keys

to select a code and ‘enter’ to place the code instead of using a mouse.

This is a very commonly used SimpleCode technique

EXAMPLE

Type Diagnosis Code: J84

Observe: Correct 3 digit Diagnosis description appear

Position: cursor in Code-Hierarchy window over J841.

Double-click over this code

Observe: Code and term fields in display area are updated

Position: cursor in Code-Hierarchy window over J860

Double-click over this code

Observe: Code and term fields in display area are updated

Another Example;

Position Cursor over diagnosis Description field

Type Term: Ectropion

Double-click on H021 in Tabular-Index tab (Coding-Wizard-with-Search & Default )

windows

CLICK the left mouse button twice

4.3.1 Refresh Notes (single-click)

The Notes window will be updated by single-clicking while positioned on a chosen code in

any SimpleCode window except the Code-Hierarchy window

EXAMPLE

Type Diagnosis Code: J391

Observe: Correct 4 digit Diagnosis description appear

Position: Tabular Index, Read / ICD10 and other windows with codes

Position: and single-click on any codes that appear

Observe: how Notes window is always updated

4.3.2 Further note on single-clicking

A single-click will not cause the current display position to be updated unless the cursor is

currently positioned within the Notes window. This is true for both diagnoses and procedures.

Manually changing double-click for code changes . . . does not cause the Notes window to

be updated. To see the current notes after a code is manually typed:

1) move the cursor out of the displayed position,

2) then single-click

3) then move the cursor back to the display area

4) then single-click over the chosen code

CLICK left mouse button

4.4 Right-Click Mouse Functions

Delete Row (Delete a coding entry)

o Right-click the row and select ‘delete row’

View Patient History Window

o Right-click within the episode, (this only activates if Patient History is not

already visible).

View Notes Window

o Right-click within the episode, (this only activates if Notes Window is

not already visible).

View Search Window

o Right-click within the episode, (this only activates if Search Window is

not already visible).

View Validation Window

o Right-click within the episode, (this only activates if Validation Window

is not already visible).

Right Click on Code, Description or Row

Select from Drop-down

4.5 Keyboard Shortcuts

Focus Shortcuts

Alt + a = Focus alphabetical Index window

Alt + c = Focus clinical terms window

Alt + d = Focus diagnosis grid and select first empty cell

Alt + e = Focus external causes or eponyms (depending on which one is visible)

Alt + i = Focus ICD drugs window

Alt + n = Focus neoplasms window

Alt + p = Focus procedure grid and select first empty cell

Alt + r = Focus Traffic Accidents or chemotherapy regimens depending on which one

is visible

Alt + t = Focus tabular index window

Function Shortcuts

Ctrl + d = Open user dictionary window

Ctrl + p = print episode report (will open preview first)

Ctrl + m = Email episode report

Ctrl + s = Save and exit

Layout Shortcuts

Ctrl + 1 = Simple layout

Ctrl + 2 = Standard layout

Ctrl + 3 = Waiting Lists and Theatres layout

Ctrl + 4 = ‘All’ layout

Help Shortcuts

F1 = Online help

F11 = View log

F12 = About

4.6 Review code-notes colour-code meanings

SimpleCode notes are colour-coded to aid your understanding. The default colour list is as

follows:

Sample Code Meaning Notes Colour

Diagnosis C031 Include advice Green

Diagnosis E00-E90 Exclude Advice Orange / Red

Procedure B045 Coding note Mauve / Violet

Diagnoses E00-E90 Coding Guidance Yellow

Diagnosis O470 Data Quality Review

Clinical Coding Guidelines

Blue

Search for colour examples within the coding notes using the above samples.

If you have more time, single-click any procedure or diagnoses code in any window other

than Code-Hierarchy and observe the colour note codes.

You can view notes, (if not currently displayed); by right-clicking on the coded line and

selecting ‘view notes’ from the drop-down window.

4.7 Quick access to Data Quality Review (DQR) special notes

SimpleCode includes Coding Clinic articles published by the NHS, linked and cross

referenced in the notes Encyclopaedia. Such notes provide authoritative comment and

actual code suggestions.

For Scottish sites, ISD Coding Guidance inserts are automatically used.

For Example diagnosis E113.

Please note that Coding Clinic and Coding Guidance notes are not the same thing.

Coding Clinic, Guidance notes are easy to spot in the Notes window:

1. Notes are coloured Royal Blue.

2. Noes are preceded by a special symbols:

4.7.1 Coding Clinic Notifications

Coding clinic / guidance information is only provided by the code notes window.

To make clinic / guidance information more noticeable when the notes window is not visible,

if a code has information on a coding clinic / guidance a CC or GC icon will be displayed

just to the left of the code in the code grid.

for Scotland for England

Position Cursor within Diagnosis window

Type Term: Procedure not carried out because

Select Z530 from the Tabular Index

Observe Notes for Z530 are in Royal Blue and proceeded by CC or CG

4.8 Type in a Term

You may not know in advance the exact code or codes that you need, therefore, an

alternative approach is to type in part of, or (rarely); a nearly complete term (i.e. code

description) into the correct display area and then search and choose a match in any one

of many other SimpleCode windows.

Using SimpleCode, this approach is made very easy. There are plenty of opportunities for skill

and experience to produce short cuts over the equivalent manual search through ICD or

OPCS volumes.

Your final choice is made by double-clicking on the chosen code. SimpleCode will then add

the correct description to the chosen code.

EXAMPLE 1 (Type in a Term)

Position: place cursor in 1st line in Diagnosis Description

Type in Diagnosis Term: renal

Single-click in turn: Tabular-index and Alphabetical Index tabs

Type Term: failure renal

Question: what happens to the above windows?

Type Term failure renal acute

Question: is the same thing happening again?

ReType: failure renal acute

Acute renal failure

Acute Acute failure renal

Acu Ren Fail

ACU REN FAIL

Acu REN FAIL

Question: Do any of the above examples make any difference to the

contents of other windows ?

Try Also: FAL ACUTE RENAL

FAIL ACCUTE REN

FAIL ACU REEN

Question: Why does the above fail to produce matches?

EXAMPLE 2 (Type in a Term)

(Note that there may be the occasional deliberate misspelling)

DIAGNOSES

Salpingitis and oophontis unspecified

Centrilobular Emphysema

Chronic parametritis and pelvic cellulites

PROCEDURES

Blepharoplasty of both eyelids

Partial restoration of crown of tooth

Stereotactic ablasion of tissue of globus

pallidus

4.8.1 Spelling a Term correctly

All spellings of terms follow OPCS, ICD standards. These standards generally use English

spelling rules. There are, however, exceptions that follow American spelling. A well-known

coding example is provided below.

EXAMPLE

SimpleCode will match on diagnosis terms Oesophag (English) and Esophag (American), but

fails to match on Osophag.

4.9 Entering multiple diagnoses and procedures

Single Episodes will usually have

multiple diagnoses and procedures.

You therefore have to learn how to

position coding details beyond the

first diagnosis / procedure rows.

Note how the line pointer always

marks the last current position row(s).

When starting to code a new Episode, the Diagnosis and Procedure windows will be empty.

To record a primary diagnosis, single-click the cursor in either the Code or Description field in

the first row. This action also establishes the current position. Follow the coding practices of

the preceding sections to establish a code and term in the current row.

To record the next diagnosis, (single-click), underneath the current Code or Description

position. Observe how the line pointer mark follows the cursor single-click to the next row.

Notice also that the row editor will not allow you to insert empty rows.

EXAMPLES

Position cursor within 1st Diagnosis Code position

Observe Line pointer points to top / first row

.

Type Code: K358

Single-click cursor underneath first line

Observe Line pointer now points to second diagnosis row

Type Code: I801

Single-click cursor underneath second line

Observe Line pointer now points to third row

Type Code: Y330

Position cursor on first line in 1st Procedure Code Field

Type Code: H012

Single-click cursor underneath first line

Observe Line pointer now points to second procedure row

Type Code: X298

4.10 Using the “up” / “down” buttons

In addition to using the cursor to land on a row, you can also

move up and down diagnosis and procedure rows using the “up”

/ ”down” buttons.

The “Up” / ”Down” buttons push the line pointer up or down the

chosen list. Note that the “Down” button will not allow a new row

to be entered.

4.11 Managing the number of procedure and diagnosis rows

By default, SimpleCode is set up to display different numbers of diagnosis and procedure

rows based on display layout that you have chosen. For example, the Simple layout may

display 16 diagnosis lines and 15 procedure lines; the Default layout may display 8 diagnosis

lines and 13 procedure lines.

4.12 Editing and viewing beyond the displayed area

To edit or view beyond the displayed number of diagnoses or procedures, (as more rows are

added and the line pointer comes close to the bottom of the input window), a slider bar will

automatically appear against the right side of the input window. Use the slider to move the

window upwards and downwards against existing rows.

EXAMPLE

Single-click: Down arrow repeatedly to move the line pointer downwards. The line

pointer will indicate the current row

If the line pointer goes beyond the visible window, drag the slider down to rediscover the line

pointer

Single-click: The up arrow repeatedly to reverse the above process.

4.13 Expanding and contracting windows (Dragging)

To display more (or fewer) diagnosis and procedure rows within their respective Diagnosis

and Procedure window’s, simply drag (resize) the chosen window boundaries to the desired

window size.

The window size can be permanently saved with a personalised layout.

EXAMPLE

Without pressing down on any mouse

button, move the mouse cursor slowly

down between window panes until the

arrow is replaced by a double-line-arrow

symbol. (The approximate position is

shown).

(Then) press down on the mouse left

button, and while keeping the button

pressed, drag the window boundary to

the desired size.

4.14 Defining upper limits to diagnoses / procedures per Episode

SimpleCode is not restricted to just the displayed diagnosis and procedure rows to create

Episodes. The total number of diagnoses and procedures permitted per Episode is

configurable through an environment file provided by Woodward Associates. Typically, this

file is updated and managed by an IT specialist after consultation with end users. (you!)

4.15 Managing morphology codes

If your PAS supports this feature, SimpleCode provides screens that allow morphology codes

to be added and maintained as part of the Episode.

As the figure below shows, all display layouts will include an extra input window (Neoplasm-

Morphology window) that supports inputting of morphology-based codes and terms.

When inputting Morphology details, if you type in a code directly, then the Code-Hierarchy

window will support you. A restriction is that the input code must begin with the letter ‘M’,

(otherwise no Code-Hierarchy window appears).

If you input a term then use the Tabular Index for support. (Using Alternate-Index tabs are

described later in Section 8 below).

4.16 Setting Neo-Natal level of care indicators

SimpleCode Version 3 allows you to set a neo-natal level of care indicator when the patient

is less than 28 days old. The indicator is used to show the level of normal to intensive care

that a baby received in the Episode.

This field will usually be correctly set through your PAS, but its current value can be

overridden.

Simply single-click on the Neonatal-Level-of-Care window scroll bar and select the

appropriate option.

If your PAS does not pass a value to SimpleCode, then it will be displayed with a level 8 value

(“not applicable”). The Neonatal-Level-of- Care window is always visible if the patient is less

than 28 days old.

4.17 Screen navigation using Fast Keys

The above figure is taken from the bottom of the Coding-Wizard-with-Search-Layout window.

In SimpleCode, all current fast key settings are defined on viewable menu tabs as an

underlined character (i.e. ‘Alt a’ = Alphabetical Index).

To operate in fast key mode, press and hold down the ALT key and ensure that ALT key

remains pressed as the second key is pressed (Chapter 2.5 covers keyboard shortcuts).

e.g. Read-Clinical-Terms window can be activated by

EXAMPLE

Type in Diagnosis Term: renal

Navigate around the screens using Fast Keys: Try ALT+ a, ALT+ c, ALT+ t

4.18 Episode validation

SimpleCode provides a useful eye-catching validation summary and additional feedback of

Episode detail through appropriate messages within the Validation window.

Invalid or questionable diagnoses and procedure rows are marked as yellow or red within the

Diagnosis and Procedure windows depending on the degree of validation error.

ALT key + c

4.18.1 Validation Form Icon

The validation window now contains an adaptive icon if it’s docked with another window or

unpinned. The icon will change based on any errors/information/warnings returned by

validation so that information is provided to the user even if the window is not visible.

4.18.2 Exiting Episodes with invalid coding

When any diagnosis or procedure is red, then the Episode is invalid and should not be

permanently stored back in the PAS at this point. If you attempt to exit the Episode when it is

in an invalid state, then an error window is automatically displayed, and you must respond

appropriately. (Your SimpleCode may be configured to not allow exiting with outstanding

errors).

When any diagnosis or procedure has a yellow colour / triangle warning, then on exit; a

warning message is issued that you must acknowledge.

4.18.3 Empty Episode validation default state

When an Episode is empty of diagnoses and procedures, its status is invalid because it does

not contain a primary diagnosis. (This conforms to "Primary diagnosis not yet defined " state).

4.18.4 The meaning of red validation

When rows with a red background colour are displayed in the Validation window, then the

Episode is in an invalid state. Such messages cannot be ignored, and should be corrected.

Common examples are 3 digit codes, codes not found in the classification, and valid codes

incorrectly used.

4.18.5 The meaning of “information icon” within validation

When colourless or has a “blue circle information icon” displayed, then the Episode is in a

valid (or acceptable) state and can be stored. A “blue circle information icon” typically

suggests that there may be an anomaly. Common anomalies are a trim point hint, or

ambiguous sex target to a specific diagnosis or procedure code. .

EXAMPLES

Select Any male patient from PAS list

Observe Validation window displays message

‘primary diagnosis is not defined’

Type in Diagnosis Code: O623 (‘Precipitate labour’)

Observe Current diagnosis row turns Yellow

Observe Validation window displays message

‘ICD10 error invalid sex for diagnosis O623 ‘

Recode as K353 (Acute appendicitis with localised peritonitis)

Observe Current diagnosis row turns neutral colour

Observe Validation window loses Yellow message

4.18.6 SimpleCode ICD and OPCS validation rules

ICD and OPCS Classification metadata rules are encoded. These rules always include:

Inconsistent gender dependent diagnoses.

Inconsistent sex diagnoses against the sex and age of the patient.

Invalid code combinations, e.g. E143+ followed by E300.

Incorrect code levels (codes not provided to a 4th level )

4.18.7 SimpleCode built in validation rules

Additional validation rules have been implemented within SimpleCode.

Most of these new rules are based on DQR clinical coding guidelines for procedures and

diagnoses (for England) and SMR validation (for Scotland).

Specific Code position rules include checks for:

Code 2 must follow code 1 (procedure C011, C031, Y763)

Code 2 should not follow code 1 (procedure W380, W382)

Code 2 is not required after code 1 e.g. (procedure O062, O060)

4.18.8 SimpleCode validation attributes

SimpleCode validation attributes help describe the accuracy of your coding. These attributes

include HRG considerations to help cost and group your coding. Costings for the latter are

managed by the HRG AutoGrouper server that SimpleCode is in constant dialogue with

during any coding effort.

SimpleCode supports costing and grouping at Episode and Spell level, but Scottish sites do

not support Spell-level validation.

SimpleCode displays Episode and Spell validation attributes in the Validation window (see

below).

Some of the above attribute values are determined directly by your coding choices, but

others are generated by the AutoGrouper server (again based on your coding choices).

4.18.9 Validation: Episode-level attributes

Episode level attributes may change their labels slightly from version to version. Common

attributes include:

Episode Duration: EpisodeDuration (aka LOS or LengthOfStay) is calculated by the

AutoGrouper server and is based on the difference between Episode start and end dates.

Trim Point: indicates the point at which an Episode is regarded as having an exceptionally

long LOS. If a patient presents with a LOS greater than the trimpoint then it may be

appropriate to review the case notes for further complications.

Dominant Procedure: is the procedure code chosen by the AutoGrouper server that best

represents the Episode.

4.19 Displaying extended patient details from Episode

You may want to display / remove more information provided about the patient through the

current episode.

Single-click double-down arrow to display additional information

Single-click double-up arrow to remove display

4.20 SimpleCode Status Display

At the bottom of the SimpleCode screen, a status is displayed identifying several key

elements.

TIP:

SimpleCode, by default, will NOT display data within the following fields until it is

sent by your PAS;

Specialty

Treatment Function

Admission Source

Admission Method

If EpStart Data, Ep End Data is showing 00:00 or incorrect then;

Your PAS is sending incorrect data or the data is corrupt.

Please send a log to [email protected] for further assistance

Indicates SimpleCode is connected and

talking to the server

Indicates which ICD/OPCS version you are currently

grouping to

Indicates which year you are

currently grouping to

Indicates SimpleCode is

connected to the Historical Database

Indicates the person logged on and using

SimpleCode

mailto:[email protected]

4.21 Printing and Emailing an Episode

You may want to print Episode details into an html or word-based report. This report can be

further edited, saved to file, or used with emails etc. The episode printout includes HRG

information as well as any user notes added by the user by default.

To request a current Episode Report

Single-click: Tools on SimpleCode menu bar

Single-click: Print Episode option

Single-clicking on the Print Episode option will cause the Episode Report to be displayed in its

own window. The figure below gives an example. Single-click on the main menu file option to

save the report to a file within your file system.

Observe Generated html of current episode

Single-click: File option to save report to file

4.21.1 Report Emailing

Episode reports used for printouts can now be emailed through a

default mail client. This can be done through Tools > Email Episode

Summary, the email icon in the task bar or the Hotkey combination

Ctrl + N. Once selected a new mail window will pop up with the

report inside the body, which is fully editable to add additional notes to the recipient.

4.22 Completing an Episode

You may want to add extra information to your Episode before finally saving and moving on

to the next Episode. SimpleCode can be configured to display optional exit screens

depending on the needs of your site.

Add Coding Status.

Single-click Coding Status scroll tag

Observe Coding Status options

Position cursor over chosen Coding Status value Double-click to select

This may not be the first time that the current Episode is coded. You, or other coders, may

have set a status of 'Partially Coded' to an Episode in all earlier sessions. Any such value will

be kept by your PAS until changed to 'Completed'.

Add Coding Source

Single-click Coding Source scroll tag

Observe Coding Source options

Position cursor over chosen Coding Source value Double-click to select

Coding Source may be set to a default value such as case notes.

Woodward Associates can arrange for this

4.23 SimpleCode help facility

The help facility can be accessed from the main menu

4.23.1 Single-click “Online Help” option

A detailed internet-based help facility is available with up-to-date information about

SimpleCode. To describe this feature in detail is beyond the scope of this course.

4.23.2 Single-click “View Log” option

Provides internal, detailed diagnostic session information - useful for Woodward Associates

support group.

Should more complex issues arise, Woodward Associates may request that your local

technical support team send a copy of this file to them.

Single-click on the save-to-file icon to begin the save process.

4.23.3 Single-click “About” option

The below window provides Support Desk email, phone details and the current version of

SimpleCode client. You may be asked to quote back the client version numbers when you

are in conversation with Woodward Associates help desk staff.

For those using imaging within SimpleCode, this is where you will find your license details.

4.23.4 SimpleCode Crashes

If SimpleCode should fail; a diagnostic screen dump of the failure will be displayed. When

you press the “Send” button, SimpleCode builds a crash dump report within another screen

format that you can send to Woodward Associates via the internet.

5 Viewing and editing whole Episodes

5.1.1 Reordering diagnoses and procedures within an Episode

SimpleCode allows you to reorder diagnoses and procedures directly within both the

Diagnosis and Procedure windows.

EXAMPLE

Single-click and hold down the row within Diagnosis window that you want to move.

Move the cursor to new position

Observe the red line move to new chosen position then release left mouse

button

Observe the row settle into new position. Other diagnoses auto adjust

5.1.2 Deleting unwanted specific diagnoses / procedures

SimpleCode allows you delete unwanted procedures and diagnoses directly from both the

Diagnosis and Procedure windows

Single-click Select any coded diagnosis line within the Diagnosis window

Press Delete key

Observe Selected diagnosis / procedure code row is removed.

Observe Other diagnoses automatically move-up-one in the order list.

5.1.3 “Clear Episode” button

Single-click “Clear Episode”

button on the SimpleCode menu bar.

Single-click “Yes” button on the

Warning window

Observe all procedure and

diagnostic details are deleted

5.1.4 Zooming in and out

Single--click “Zoom-in” (for smaller text) or “Zoom-out” (for Larger text) buttons

Observe

Episode text and headers shrink or grow. Only one level of shrink or grow is supported. Font

change size does NOT apply to the NOTES window.

Note that using the SimpleCode menu bar VIEW -> FONT and choosing Standard or Large

Font Size will achieve the same.

SimpleCode fonts are also directly affected by Windows operating system font sizes. When

you enter SimpleCode, the size of font is determined by Windows operating system current

screen font settings.

If you want to make SimpleCode start with a display in smaller or larger font sizes, then use

your Windows operating system directly to set a default font size to suit your taste. The above

“Zoom” buttons always work from the current Windows operating system settings.

6 Using Spell detail and patient history to aid coding

Note: For Scotland please note the terminology used here:

Episode (England) = SMR (Scotland)

Spell (England) = Episode (Scotland)

To help you code more effectively, SimpleCode provides some general Spell support across

all display layouts, plus access to the Patient History and Predictive-Coding windows in the

Wizard display layouts.

6.1.1 How Spells are recognised

SimpleCode can recognise a Spell ID if provided from your PAS, and will organise Episodes

accordingly. If a Spell ID is not passed, the SimpleCode Patient-History window will organise

Episodes by attendance and discharge dates.

6.1.2 Using Spell-Episode tabs

By default, across all display layouts, when SimpleCode is aware of one or more Episodes

within a Spell, it will display Episodes above and across the Diagnosis window using a set of

tabs. The tabs display Episode start / end dates.

Usually, all the tabs, except the currently edited Episode tab, will display a lock symbol

indicating that these Episodes are read only. Tabs with a lock symbol can be opened and

displayed, but not edited.

Note that code details from these Episodes can be added to the currently edited Episode

using a combination of Patient-History and Coding windows.

6.1.3 Editing a whole Spell within one SimpleCode session

Your PAS may support SimpleCode Version 3 to edit any-to-all of the Episodes in a Spell.

When this feature is used, no locks will be shown on tabs. All Episodes are saved back to the

PAS when the “Save” button is single-clicked. If there are any validation messages against

any of the Episodes, then SimpleCode will switch to the flagged Episode to allow you to

resolve the issue.

6.2 Viewing patient history

Not all display layouts automatically present the Patient-History window. Display layouts that

do show by default are: Simple, Standard and All.

To enable Patient-History when not present – Select View > Patient History

6.2.1 Spells in Patient-History

SimpleCode Version 3.3 displays a history line for the current Spell / Episode.

SimpleCode Version 3.3 displays a light blue background to the Spell line in the Patient -

History window. Related Episodes are grouped underneath.

Patient History - New Functionality

The new patient history window lets you look through the patient records quickly and easily

so you can:

Copy relevant codes to the current record

review the patient for comorbidities you might expect to find in the patient notes

Click a BLUE line to see the SPELL details (Scotland = Admission)

Click a WHITE line to see EPISODE details

(Scotland = SMR Episode)

EPISODE details, including who coded an episode (Scotland = SMR Episode)

EPISODE coding click on a checkbox to add a code(s) to the

current episode

(Scotland = SMR Episode)

See next page for the description of these icons and what they do

Patient History Icons - click on the relevant icon below to show/hide information (each icon

works as a toggle switch; click-to-show and click-to-hide)

ICON SHOW

Show all patients history

Show Emergency Re-admission episodes

Show just the patient episode records with the same

specialty

ICON SHOW / HIDE

All of the conditions listed below

Personal History

Family History

Long Term Conditions

Sequelae

Congenital Conditions

Notifiable Conditions

6.3 Taking code detail from other patient episodes

Within the Patient-History window, when you single-click on a chosen related Episode, then all

its diagnosis and procedure codes are displayed in the Coding window. By choosing and then

ticking diagnosis and procedure boxes from this window, the chosen codes are automatically

appended to the current episode.

6.4 Other Spell level features

The Spell HRG is only displayed when all the Episodes within a Spell are coded to the point

where each has a primary diagnosis.

Where your PAS supports HRG Version 4, then Spell HRGs have extra validation features.

Please note that Spell support is mainly passive to the coder. As described earlier, you cannot

edit other Episodes in the Spell directly through the current Episode unless your PAS supports

this feature – this is not a default. Normal practice will be for you to exit / re-enter / edit those

Episodes using SimpleCode.

You cannot change Episode / Spell relationships: i.e. switch an Episode to another Spell, using

SimpleCode.

6.4.1 Spell information adding / editing admission notes

Spell support allows you to input useful notes about the selected Spell. Add, change or delete

notes simply by pressing the “Admission Notes” button (from within the Notes tab) - an Edit-

User-Notes window is displayed in which notes can be added, or edited.

The “Admission Notes” button will be automatically displayed at the top of the Notes window

for Episodes within the Spell. All Episodes within a Spell share the same admission notes.

SimpleCode Version 3.1.1 displays admission notes within the Notes window with a yellow “post

it” background. All admission notes are viewable within the Notes window immediately they

are entered.

6.4.2 Spell validation information

The Validation window displays Episode and Spell information and validation messages.

Commonly displayed Spell-level information is listed below.

If the message "UZ01Z – Data invalid for grouping" is displayed this indicates that the

Spell is not yet completed. SimpleCode recognises a Spell as complete when all the

Episodes in the Spell have a primary diagnosis.

SpellHRG will have a grouped code now that the Episode is (at least) partially coded

across all Episodes.

Tariff (behaves as a Spell-level-Tariff) represents the base amount of money that a

SpellHRG will pay.

Spell Length of Stay is calculated by the AutoGrouper server to show the number of

whole days (actually the number of night stays) that a patient Spell covers.

SpellTrimpt HRG Version 4 provides a Spell-level trim point based on the SpellHRG

(which in turn is based on the procedure that has the most effect on the Spell).

SpellDGVP is the dominant procedure chosen by the AutoGrouper server across all

Episodes within the Spell.

Unbundled HRGs represent typically more expensive procedures codes (codes with

very high tariffs) within the Spell that cause additional (“sub”) HRG codes to be

grouped. The additional HRG codes are listed here.

7 Using SimpleCode terms more effectively

7.1.1 SimpleCode returns too much Information

Type Diagnosis Term: renal

Observe Tabular, Alphabetic-Indices, Read-Clinical-Terms

windows have many entries

Note by default, each list is limited to 100 entries

Provide more search words, e.g. acute renal, acute renal fail

Observe fewer matched entries in above windows

OTHER EXAMPLES

Compare diagnosis injury vs fall

Compare procedure hip vs Herbert

Compare diagnosis fall vs animal fall

7.1.2 SimpleCode returns no or little Information

Type Diagnosis Term: IHD

Observe Tabular, Alphabetic Indices windows have no entries

Observe Read-Clinical-Terms window has many entries

Consider searching READ terms for equivalent

ICD codes. READ codes are descriptive, low-

level and sometimes more up to date

OTHER EXAMPLES

Compare diagnosis ectropian vs ectopion

Compare diagnosis aminal vs animal

Compare procedure hip vs Herbert

7.2 Managing “Dagger*” Codes using the Alphabetic Index

Type Diagnosis Term: Nephrosis diabetes mellitus

Observe Matched entries in the Alphabetic-Index window

Position Cursor over E142+ line in Alphabetic-Index window

Double-click on this line

Observe The primary (dagger) and secondary (*) codes are

both transferred to 2 code positions in the data

Entry Panel. (The Episode has been given 2 related

diagnosis codes).

Note that if a coded row exists immediately underneath the dagger line, then SimpleCode will

automatically insert the *code above the existing coded row.

7.3 Manually setting “dagger *” codes

Many coders know in advance the “dagger*” codes required for an Episode. You may simply

type in the codes over 2 consecutive display positions.

8 Accessing Alternative-Indices tabs

Many extra tabs are based on specialist indices provided through ICD Volume 3 and OPCS

documentation. The index tabs will adjust automatically when you switch coding between

Diagnoses, Procedures and Morphology. Note that some sites use other alternative indices

built on request by Woodward Associates.

8.1.1 Commonly available diagnosis indices

Common secondary indexes include

Tabular Index

Alphabetic index

Read Clinical terms

Neoplasms

External Causes

Traffic Accidents

ICD Drugs (plus SNOMED branded drugs)

8.1.2 Commonly available procedure indices

Common secondary indexes include

Tabular Index

Eponyms

Chemotherapy regimens (Procurement and Delivery)

Alphabetic index

Read Clinical terms

8.1.1 Commonly available morphology indices

The only populated secondary index is the Tabular index

8.1.2 Lead Term Search

The Alphabetic Index can be made to return only Lead Term results when entering a

description. This facility can be switched on and off via the associated icon.

Lead Term switched ON

Lead Term switched OFF

8.2 Commonly used Alternative-Indices

8.2.1 Alternative- Index: neoplasm lists

Type Diagnosis Term: heart

Observe Neoplasm index tab has matched codes

(Optional Single-click ) on a selected neoplasm code

(Usually you must single-click on a row of codes)

A second level selection screen appears.

Single-click on the chosen neoplasm

Observe The chosen neoplasm will be part of the Episode

Other Examples View neoplasms for stomach, nerve

8.2.2 Alternative-Index: external cause lists

External causes often require a preceding “T” code. This must be provided by the coder

Type Diagnosis Term: left in body

Observe "External Causes" window has matched codes

(Double-click) on the external cause code

OTHER EXAMPLES View external causes for: needle, stairs and ladder

8.2.3 Alternative-Index: traffic Accidents

ICD-10 Volume 3 Section 2 displays a grid table of accident victims / mode of Transport in

collision with other victims / modes of transport.

The Grid is placed just before the main External Causes of Injury Index. The Accidents Table

uses the term field to provide the same grid co-ordinated information.

Type Diagnosis Term: car ped [estrian]

Observe Traffic-Accidents window has matched codes

(Double-click ) on the chosen external cause code

(If you choose a 3 digit code then double-click on

a 4 digit code from the Code-Hierarchy window

Other Examples pedestrian, pedestrian truck

8.2.4 Alternative-Index: Read clinical terms

Type Diagnosis Term: COAD

Observe READ / ICD mapping shows matches

OTHER EXAMPLES COPD, TB, IHD, PSP, William syndrome,

Depressive disorder

FAP, CAD, ALD, ACS

8.2.5 Alternative-Index: ICD (and Snomed) drugs

Type Diagnosis Term: Aspirin

Observe ICD Drugs tab displays a list has matched codes

(Optional Single-click) on a selected drug code (Usually you must single-click on

a row of codes )

Observe A second level selection screen appears.

(Optional Single-click) on either the category, code or description of the type of harm

Observe The chosen harm becomes part of the Episode

Type Diagnosis Term: Calpol (A brand name)

Observe ICD Drugs list has no matches

Observe Snomed list has matches

Single-click on a selected Snomed drug code

Observe control is passed back to ICD tab with chosen brand drug

as ICD Drug

OTHER EXAMPLES View drugs for anti-depressant, beta blocker Co-prox

(look at read / ICD10 mappings)

8.2.6 Alternative-Index: eponyms

(Eponyms are procedures named after individual clinicians)

Type Procedure Term: Vulpius

Observe EPONYM index has entries

Double-click T705 – Vulpius

Observe Episode is updated with 2 procedure codes

T705 and Z581

OTHER EXAMPLES Adams, Bassett

9 Using SimpleCode coding wizards

9.1.1 Introducing the idea behind coding wizards

The Coding-Wizard layouts list codes that are likely to be of use to you. The lists are based on

the consultant, consultant specialty, primary diagnosis and primary procedure codes.

The lists of primary codes are potentially derived from other Episode data of all patients from

your site.

The lists of secondary codes are based on national grouped data.

9.1.2 Using coding wizards

Two coding wizards are available that offer code lists for making better informed choices. Both

wizards are probably of more value to experienced coders who can make more

discriminating coding decisions.

Coding Wizards are only available through the ‘ALL’ layout or Personalised layout

9.2 Introducing the Wizard-Primary-Diagnosis (W-P-D) window

This window is populated by SimpleCode based on your choice of primary diagnosis for the

episode. The displayed codes and The "relevance score” will always be derived from Episodes

coded for the current patient AND all other patients on your site. The data is stored and

managed automatically by SimpleCode in its historic database.

9.2.1 Wizard –Primary -Diagnosis window with (or without) a primary diagnosis

With or without a primary diagnosis coded by you, this window displays diagnosis codes that

represent a generalised picture of the clinical work by the Episode consultant. The "relevance

score” filter reveals the quantity (and so the relative importance) of codes to the work of that

consultant for Episodes managed at your site.

SimpleCode Version 3 completely controls the displayed codes in the Wizard-Primary-Diagnosis

window. By default, the Episode’s Consultant is used.

SimpleCode Version 3 allows further filters by ticking the appropriate arrowed boxes.

Options available are:

1. consultant only

2. specialty only

3. consultant and specialty

Wizard Primary Diagnosis Window

9.3 Introducing the Wizard-Secondary-Diagnosis window

This window displays diagnosis codes and a "relevance score" that indicates how often a code

has been used in conjunction with the primary diagnosis coded for the episode. If you change

the primary diagnosis code, then codes displayed in the Wizard-Secondary-Diagnosis window

are likely to change.

Many primary diagnosis codes do not have any associated secondary diagnoses. The displayed

codes and scores are always based on national coding data and NOT site episodes.

The "CC" column stands for Co-morbidity or Complication. This column may display a gold star

(not displayed above) indicating that the code exists in the HRG complication lists.

Each Wizard-Secondary-Diagnosis window row has a check box that if ticked, will add the

diagnosis into the current episode in the next available row.

Wizard Secondary Diagnosis Window

9.4 Introducing the Wizard-Primary-Procedure (W-P-P) window

When coding procedures, the Coding-Wizard displays two additional windows: Primary and

Secondary Procedure. Like the Wizard-Primary- Diagnosis window, the Wizard-Primary-

Procedure window shows primary procedures and "relevance scores" relevant to the

consultant on the episode. SimpleCode Version 3.1.0 allows that data can be filtered by

ticking consultant and main specialty boxes.

9.4.1 W-P-P window without a primary diagnosis

The Primary-Procedure” window will display only procedure codes that represent a generalised

picture of the clinical work by the Episode consultant sorted by "relevance scores".

9.4.2 W-P-P window with a primary diagnosis

This window displays procedure codes that map to other Episodes from your site that share the

same primary diagnosis code. (Remember that other Episodes may include Episodes for other

patients at this site). Sometimes, there will be no procedure codes that correspond to a

diagnosis code.

Wizard-Primary-Procedure window may be useful in selecting a procedure code that is

commonly employed with your chosen primary diagnosis for the current Episode consultant.

Wizard Primary Procedure Window Wizard Secondary Procedure Window

9.5 Wizard-Secondary-Procedure window with primary diagnosis

Like the Wizard-Secondary-Diagnoses window, this displays secondary procedure codes and

relevance scores taken from national grouped data sources stored in the SimpleCode historic

database. Procedures may include NEC and NIC codes.

In the figure above, a primary diagnosis code “I48X” is entered. This code is used by SimpleCode

to determine the display of site-based primary procedures in the Wizard-Primary-Procedure

window. From this list, code “X501” has been chosen by the coder as the primary procedure.

This, in turn, causes the Wizard-Secondary-Procedure window to display related national

grouped codes. Where site codes are displayed, an additional column marked with a gold star

is recorded (not shown above).

9.6 Default Consultant/ Surgeon Fields

The Surgeon/Consultant field in the procedure grid can now by default be set to the episode

Surgeon/Consultant.

10 SimpleCode Advanced Screens

10.1 Why a user local dictionary facility is useful to you

SimpleCode provides a powerful user local dictionary facility for you to add and access

procedure and diagnosis codes and descriptions under your own local descriptions ('Local

Codes'). You can also use this facility to add personal notes to ICD and OPCS codes – this

could be a practical replacement for all those hand-written notes in the green volumes.

10.2 How to access the local dictionary

To access the user local dictionary

Single-click: Tools on SimpleCode menu bar

Single-click: User Dictionary

Observe User Dictionary screen is displayed

10.2.1 Adding single or strings of 'local' codes

(From the drop-down, single-click on “User Dictionary” and the User-Dictionary window will

open – see below).

By default the Custom-Searches tab is displayed, filter is set to ICD10 and the visibility to Private.

Single-click: on the New tab and select from “New Search” or “New Code Notes”. The User

Dictionary will open and display a new window i.e. ‘Edit Dictionary’ or ‘User Notes’ -

depending on which was selected.

New Search: You can add single or multiple collections of codes to the dictionary and give a

personal description. If you enter the personal description it will be displayed in the Tabular-

Index (Standard/All layouts).

New Code Notes: You can add a personalised description/information/comment to an

existing code – i.e. B664 Paragonimiasis - Not to be used for lungworm infection

10.2.2 Using the ‘User Dictionary’

New Search: (After entering a custom search into the

user dictionary). Enter your custom description into the

description field within diagnosis or Procedure and select

Tabular Index. Your custom search should be visible.

Single-click on the entry within the Tabular Index window

and the code or codes will be inserted into the Diagnosis

or Procedure windows.

New Code Notes: (After entering a custom Code Note

into the user dictionary). Enter the specific code into

diagnosis or Procedure. Your custom notes will appear in

Yellow within Coders Notes (coder notes need to be

enabled).

Note: Local codes can be marked as public or private.

Public codes can be shared by all coders using

SimpleCode. Private codes are shown only to their

creator.

10.2.3 Add a hyperlink through User Dictionary

Select New Hyperlink from the drop-down menu within User Dictionary. This will produce the

‘Add External Reference’ popup where the link details can be checked over, or a web

address can be added manually.

The link will be validated to make sure that it is a valid address

and the name will be populated automatically based on the

contents, if another name is required it can be modified.

Once Ok is clicked the reference will be shown in the coders

notes window whenever the code is typed.

External references can also be used in the same way as

custom searches and code notes through the user dictionary

window. They can be shared to all users by checking the

public box, edited and deleted.

10.2.4 Hyperlink through drag and drop

You can add a hyperlink to an existing code by:

Enter a valid code within SimpleCode – Diagnosis or Procedure window

Open up your external internet browser

Navigate to the appropriate internet reference page (enter the web address)

Once the page is loaded, place your mouse over the ‘far left’ (i.e. in front of the

http://) part of the web address

Click and hold down the left button of you mouse

Drag your link over to the CODE you wish to reference within SimpleCode (Diagnosis or

Procedure) and release the left button

A new pop-up window will now appear populated with the code, description, URL

reference and reference name

Select okay

Within the Notes window, you should now see your External References displayed

against the appropriate Code.

Automatically loaded from SimpleCode

Details entered by user

10.2.5 Modify an external Reference (Hyperlink)

You can modify or delete an existing hyperlink(s) by;

Within the notes window select Hyperlinks

Select Edit Hyperlinks

Select the appropriate Hyperlink you wish to modify

Select the appropriate function (icon) edit or delete

10.2.6 Adding personal notes to ICD and OPCS codes

You can add your own notes to ICD and OPCS codes. These notes will be displayed in the

Notes window alongside the standard classification notes.

SimpleCode displays such notes with a yellow post-it note type background colour to help

distinguish them from other Notes window sources.

Code notes can be marked as “public” or “private” by ticking the box. Public notes are

shared by all coders using SimpleCode. Private notes are displayed only to their creator.

11 Creating your own Display Layouts

In addition to the four display layouts (see Section 3), SimpleCode allows you to create your

own display layouts. Personalised display layouts are available to you through your own user

ID. Other coders can create their own personal display layouts without interfering with your

display layouts.

Personal display layouts can be created in two ways:

Make temporary changes to any of the four provided SimpleCode display layouts. Any

such temporary changes will be used across different sessions until you change to a

different display layout.

(Or) create a new permanent display layout that suits you.

11.1.1 Edit a current display layout to make temporary changes

Choose a display layout and alter it to your liking. Alterations can include

Drag / drop screen boundaries

Include / suppress current windows

Create new windows

For more detail about dragging see Section 4.13. To include or suppress alterations use the

“View->Search Windows” link on the Menu bar. By ticking or un-ticking window names,

windows are added or removed from the display layout. Note that any of the four default

SimpleCode display layouts can be edited in the same way.

In the example above, The Alphabetical-Index entry has been un-ticked and has been

removed from the current display layout. To re-instate it, simply re-tick.

11.1.2 Creating a new personalised display layout

A very useful feature is to create an additional populated window. A good example is to

make the Read-Clinical-Terms tab a permanently populated window in addition to the

Alphabetic-Index or Tabular-Index tabs.

Position: Default layout

Type Diagnosis Term: Renal

Single-click: Alphabetic-Index tab

Left Single-click and drag to screen right: Read-Clinical-Terms window

Observe: "Blue box" effect and drag the screen to the right.

When the drag is completed, note the new window

11.1.3 Permanently saving your new personalised display layout

Single-click the "Save Layout" button on the toolbar to save your personalised layout.

Simply type in a new layout name in the Name field and single-click OK.

Save Layout Button

11.1.4 Managing your new personalised display layout

Single- click the "Manage Layouts" button on the toolbar to set up display

characteristics for your new display layout

Single-click on the layout you wish to modify

Single-click on red cross to delete the display layout

o Or single-click on the yellow pencil to change the display layout name

Then single-click “Close” button

Manage Layouts Button

11.1.5 Use your new personalised display layout

Single-click the Layout-Selection window scroll button, then choose from the options menu by

single-clicking your new personalised display name label.

12 SimpleCode Image Library (Optional)

Image Browsing via the SimpleCode Image Library, has been introduced as a coding aid for

version 3. SimpleCode image library facility is only available via a valid user license. For further

details please contact Woodward support ([email protected])

12.1.1 Enable Image Browsing

Image Browsing can be enabled via the “View” option on the SimpleCode Menu Bar.

12.1.2 Image window

The image window can be found next to Notes and Validation tabs as “Anatomy and

Physiology” tab. This tab is available in all SimpleCode Layout options (Simple, Default, Coding

Wizard and Coding Wizard with Search).

Anatomy and Physiology window is not part of the default SimpleCode Layout , therefore, if

you change your SimpleCode Layout, you will need to enable image browsing again

You can save your own layout to include image browsing

By default, if you had image browsing enabled when you closed SimpleCode, it will be

enabled when you reopen SimpleCode.

The Anatomy and Physiology window can be rescaled

12.2 Viewing Images

There are two ways of viewing images:

1. Image Search Facility (Searching by entering text within the Description field)

2. Entering a procedure site Code

12.3 Image Search Facility

The image search facility is automatically activated by entering a minimum of 3 characters

within diagnosis Description or procedure Description fields.

If there is a match: A Search Results box will appear within the “Anatomy and

Physiology” box with a list of images that contain the text you have entered within the

Description field. If the search results extend beyond the box size then a scroll bar will

appear allowing you to scroll down through the search results.

By clicking on one of the results, within the Search Results box, a related image will

appear below with the corresponding text highlighted in yellow.

Illustrations Copyright © 2014 Nucleus Medical Media, All rights reserved.

www.nucleusinc.com

Example:

1. Enter the letters “ lat “ in either the diagnosis or procedure Description

2. In the Anatomy and Physiology box a Search Results box will appear

3. Within the Search Results box scroll down using the scroll bar and click on “Male

Muscle Head Anterior”

4. Male Muscle Head Anterior image will appear with the highlighted text

“Platysma”

Question: Why has the word “Platysma” been highlighted?

Answer: the word “Platysma” has been highlighted because the letters “lat” reside within that

word.

You can of course enter whole words – if you enter the word “heart” then the Search Results

window will display images with the title Heart or images that contain the word heart (Heart,

The Circulatory System).

If there is no match: If there is no match to your word string, then the previously

displayed image will remain and the Search Results box will not appear

12.3.1 Images via Site Procedure Codes

You can also call up images by entering a site procedure code.

Example:

1. Enter the procedure site code Z604

2. Within the Anatomy and Physiology window you will see the related image “Muscle of

Back”

3. Note: No text is highlighted and no Search Results box is available as site codes are

specific

12.4 Images support for Caché

Images are now available to any client that uses a Caché database.

12.5 Image Browser Control

The image browser has been improved to prevent overlapping of image labels.

There is an image zoom control which can be used either

Through a new slider above the image or

With the mouse scroll wheel

If the image has been expanded to greater than the available window size, you can now

move the image within the window with the left mouse button down.

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