Medical Director – using the Clinical Diagnosis Coder
In MD3 there are two ways to enter past medical history items:
o Pick from list (Coded) or
o Free Text (Uncoded)
Both of these options are available to use in Past History. However if you have entered a diagnosis into the Past History tab that was not selected from the ‘Pick from list’ it will not be internally coded, and as such will not be found when doing searches. This is particularly important for Chronic Disease Management or when using some supplied decision support options.
For example, if you typed ‘Hep B’ into the uncoded section of the Past History tab, rather than using ‘Hepatitis B’ from the drop down list (or any of the other codes related to HBV, it will not be found when you do a search for patients with Hepatitis B.
MD 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.
Open MedicalDirector Maintenance, then click MedicalDirector Clinical under Database Tasks, then open “Diagnosis Coder”.
o 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
o 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
o The 
button will attach the code for that diagnosis to the coded entry on the right
o The 
button will change the diagnosis on the left to that on the right i.e. if the word was misspelled
o 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.
