The automated coding feature is designed to extract structured data from consultations, enabling you to enter information accurately into the Electronic Health Record (EHR)
As a product for General Practitioners, medical codes relevant to primary care are prioritised. The most critical codes for EHR entry are those linked to reimbursement through the Quality of Outcomes Framework (QOF) specifications. Particularly important are SNOMED codes related to examinations of the patient's vitals—these report observable metrics that describe the patient's condition
Once a consultation has been completed with Surgery Intellect, the transcript is generated within the Intellect Window
Based on the content of the consultation, Surgery Intellect will identify Medical Codes that may be relevant. Each item displays the code and any observable values, as well as showing the consultation content that prompted the code to be generated
Available Medical Codes:
1. Systolic arterial pressure
Synonyms: SAP - systolic arterial pressure
Unit: mmHg
2. Diastolic arterial pressure
Synonyms: DAP - diastolic arterial pressure
Unit: mmHg
3. Heart rate measured at systemic artery
Synonyms: Pulse rate, PR - Pulse rate
Unit: bpm
4. On examination - pulse rhythm regular
Synonyms: O/E - regular pulse, O/E - sinus rhythm, O/E - pulse rhythm regular
Unit: None specified
5. On examination - irregular pulse
Synonyms: O/E - irregular pulse
Unit: None specified
6. Respiratory rate
Synonyms: BR - Breathing rate, Breathing rate, RR - Respiratory rate, Respiratory frequency, Rate of respiration
Unit: resp/min
7. Core body temperature measured at tympanic membrane
Synonyms: Tympanic temperature, Aural temperature
Unit: °C
8. Standing height
Synonyms: Height
Unit: m
9. Body weight
Synonyms: Weight
Unit: kg
10. Waist circumference
Synonyms: None listed
Unit: cm
11. Hemoglobin saturation with oxygen
Synonyms: Haemoglobin saturation with oxygen, O2 - oxygen saturation, Blood oxygen saturation
Unit: %
12. Blood glucose level
Synonyms: None listed
Unit: mmol/L
13. Date of last menstrual period
Synonyms: LMP - Last menstrual period
Unit: DD/MM/YY
14. Peak expiratory flow rate
Synonyms: PEF - Peak expiratory flow rate, PEFR - Peak expiratory flow rate
Unit: L/min
15. Forced expired volume in 1 second
Synonyms: FEV1 - Forced expired volume in 1 second
Unit: L
16. Forced vital capacity
Synonyms: FVC - Forced vital capacity
Unit: L
17. Capillary filling, function
Synonyms: Capillary filling, Capillary refill time, Capillary filling time
Unit: seconds
18. Cigarette consumption
Synonyms: None listed
Unit: /day
19. Rolls own cigarettes
Synonyms: None listed
Unit: g/week
20. Cigar consumption
Synonyms: None listed
Unit: /day
21. Alcohol units consumed per day
Synonyms: None listed
Unit: /day
22. Alcohol units consumed per week
Synonyms: None listed
Unit: /week