PRSB publishes guidance on clinical coding for coronavirus care

The Professional Records Standards Body (PRSB) has published guidance on how clinical information for coronavirus care and treatment should be coded.

The guidance, written in collaboration with NHS Digital, has been assembled from a variety of sources to help health and care professionals manage clinical information to improve patient care.

It comes after NHS Digital published the UK SNOMED CT codes for Covid-19. The guidance will also support central data collections to help manage the pandemic and aid research and planning.

Professor Maureen Baker, chair of the PRSB, said: “In order to provide timely support for health and care professionals during the pandemic, we’ve produced this new guidance to help manage the clinical information being shared between systems.

“Having the right information will support professionals in providing the best quality care they possibly can for patients. This information will also help with monitoring and managing the health and care systems and will be essential for researchers who are supporting the fight against the pandemic.”

According to a statement on the PRSB website the guidance sets out Covid-19 clinical information that will be coded in a “simple and easy to apply list” including testing, diagnosis and treatment.

“We will be working with clinical colleagues in our member organisations to ensure the information is shared widely and that any feedback about implementation or additional needs for managing the pandemic and its aftermath are met,” it adds.

The Covid-19 SNOMED CT codes include:

• Risk category
• Isolating/shielding advice
• Encounter and advice
• Exposure
• Signs and symptoms
• Swabbing
• Tests and test results
• Clinical and test result interpretations/disease labels
• Severity assessment
• Complications
• Vaccination

PRSB is working with NHS Digital and the Faculty of Clinical Informatics to develop a short list of five to six codes considered to be most useful when recording Covid-19 information.

They’re intended for use by GPs; primary care nurses; pharmacists; community based mental health clinicians; and community based clinicians

System suppliers will be updating their systems and rolling out Covid-19 related SNOMED CT codes “urgently”, according to the PRSB.

A webinar to discuss the guidance will be held by the PRSB on 9 April. For more information or to join the webinar email info@theprsb.org.