Using OneCoding Template

Using OneCoding Template

Purpose:

This template is for use by clinical coders when receiving external communications from other agencies.

What does it actually do?

It is designed to contain everything a clinical coding team would need to process letters, record relevant information for QOF and ensure that all information received from third parties is recorded accurately and with consistent coding.
This includes:

General information

  1. Recording the type of communication received
  2. Recording a 111 disposition
  3. Recording a cancelled/rearranged/DNAd appointment
  4. Recording admissions and discharges

Observations

This page allows for the recording of important social information - such as smoking or alcohol intake, as well as common examinations such as height, weight, BMI and blood pressure

Actions

This page allows for the recording of specific actions that may be required in primary care, such as:
  1. suture removal
  2. blood test
  3. GP review
  4. medication request
  5. onward referral

Allergies and adverse reactions

This page allows the user to record any allergies or adverse reactions

Cancer

This page allows for specific information to be recorded about patients with a cancer diagnosis - recording:
  1. Chemotherapy
  2. Radiotherapy
  3. Hormone therapy
  4. Brachytherapy
It also gives users supporting information they may wish to send to the patient as well as allowing the recording of gold standards framework status

Screening

On this page, users can record screening information about:
  1. Cervical screening
  2. Breast screening
  3. Bowel cancer screening
  4. Abdominal aortic aneurysm screening
  5. Retinal screening

Procedures

This page allows for the recording of common procedures undertaken in secondary care settings, such as:
  1. Biopsy
  2. Appendicectomy
  3. Cholecystectomy
  4. Tonsillectomy
  5. Colonoscopy
  6. Cystoscopy
  7. Colposcopy
  8. Duodenoscopy
  9. Endoscopy
  10. Gastroscopy
  11. Laparoscopy
  12. Sigmoidoscopy

Common scores

Users can record common scoring metrics here - such as PHQ9 or GPCOG amongst others

Results

This page allows for the standardised recording of results - for blood results, cardiology results (echo etc) or radiology.

Fracture

This page allows users to record fractures and flags for consideration of fragility fractures.

QOF New diagnoses

Where a new diagnosis has been recorded in a communication, users can check on this page to see the requirements for this diagnosis in QOF.  This means that this data can be recorded in a straightforward way, minimising the chasing up or correcting of coding later on.

What does it look like?

The following are a couple of examples of the pages, and how they appear:


   
Supporting CQC key areas
Safe
Safeguarding and protection from abuse
Managing risks
Medicines management
Effective
Assessing needs and delivering evidence-based treatment
Monitoring outcomes and comparing with similar services
Staff skills and knowledge
How staff, teams and services work together
Consent to care and treatment
Caring
Privacy and dignity
Responsive
Person-centred care
Taking account of the needs of different people
Timely access to care and treatment 
Well-led
Leadership capacity and capability
Vision and strategy
Culture of the organisation
Governance and management
Management of risk and performance
Management of information
Learning, improvement and innovation

System Dependencies:

There are no dependencies for this template.

Fitting your practice

There aren't any alterations needed to your practice to utilise this template.   Your clinical coders need to know that it exists and how to find it.

How to get it

This template can be found on the OneAdmin Template. 



Alternatively, you can launch it via  F12 key and save as favorite. 

Support Information

Development Log

v6.4

Published 24/07/2025.
Initial release

Communications Log

Primary Care IT are pleased to announce the release of our new OneCoding.  This template contains everything that a clinical coding team would need to be effective in their work.  It aids teams to record information in a structured and consistent way.  Where new diagnoses have required contractual actions, these are highlighted.  Where common procedures have been performed in secondary care or where follow up in primary care is needed, users can record this in a standardised way using the template.  

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