Bite-sized learning - be SCAR in EPR

Clinical coding is reliant on the quality of the documentation in EPR. The coders count on our clinical teams to clearly document what is treated or investigated during a patient's stay. So remember be Specific, Complete, Accurate and Relevant.

Specific - For example: Don't just write diabetes - is it type 1 or 2?; If a patient has been admitted with an injury tell us the cause; If you've injected into the spine - which area of the spine have you injected into?

Complete - Clearly record all diagnoses (including comorbities) and procedures as well as any complications

Accurate - It may sound simple but please don't record conditions if the patient doesn't have them

Relevant - Only document conditions that are relevant to the patient's stay