Discharge Letter Templates (Page 4 of 7) in pdf

Discharge Letter Templates Page 4

Discharge Letter Example 4

Letter Date: xx/xx/xxxx

Reference:

Dictated Date: xx/xx/xxxx

Transcribed Date: xx/xx/xxxx

PATIENT; ………D.O.B:……..; CHI: ……….

Admission: Specialty -Orthopaedics….; Ward – xx

Consultant: Date of Admission - xx/xx/xxxx

Date of Discharge - xx/xx/xxxx; Discharged to: [ . . ]Follow Up: [ ]

Diagnosis Site Side

Primary arthritis of joint, specify (ICD10: M19.0) Knee Right

Long Term Conditions: Primary arthritis of joint, specify

Date Procedures/Interventions/Operations

xx/xx/xxxx PRIMARY TOTAL PROSTHETIC REPLACEMENT OF KNEE JOINT

NEC

Clinical Comments:

This [ . . ] year old gentleman underwent right total knee joint replacement under

Mr [ . . ]. No complications post-op or intra-operatively. NV intact. Obs

stable, fit for discharge.

Treatments: None recorded.

Follow-up arranged: [ ]

Planned Outpatient

Investigations:

Yours sincerely,

Dr [ . . ]

INFORMATION COMMENTS FOR CODING PURPOSES:

In this example the diagnosis description in the text and ICD10 code provided by the

clinician are not consistent (the code description for M19.0 is Primary arthrosis of

other joints) – the text stating right knee has been added on as supplementary

information. There is a specific code available for knee arthritis (M17). The ‘Primary

arthritis of the joint’ description provided does not specify whether the arthritis is

osteoarthritis or rheumatoid arthritis although the addition of information about it

being ‘primary’ is useful and can be coded. If further detail had been provided in the

summary as to whether the joint was cemented, uncemented or hybrid the coder

could have also included this additional level of detail.

Discharge Letter Templates Page 4