Juliette is coding the way to high quality digital information

Meet Juliette, one of our brilliant Health Information Managers, who works to develop, implement and manage patient clinical and administrative data that comes through our health service.

Juliette is a Health Information Manager at Peninsula Health.

In a role focused on the clinical coding of recently discharged patient episodes, Juliette’s first year at Peninsula Health has been a delight.

Juliette translates medical terminology as written by our clinicians to describe a patient’s complaint, problem, diagnosis, treatment or reason for seeking medical attention, into a coded format that is recognisable on a national and global scale.  

“This involves reading through inpatient notes from within the Clover Electronic Medical Records (EMR) and Digital Medical Record (DMR) systems,” says Juliette. “We then apply International Classification of Diseases (ICD) codes to significant patient conditions and diagnoses that were treated, investigated, monitored during their admission.”

“We also apply codes to any significant procedures undertaken, i.e. those surgical in nature or those that carry a procedural risk.”

“We really focus on the documented plans of care to help determine if a condition is to be coded or not. Which means our coding is only as good as the accuracy of documentation within the patient’s record.”

“We want to ensure that our coding best reflects the resources used to help provide a clinical overview of that patient’s journey.”

“Peninsula Health has an extremely varied case mix. Our work may range from coding a straightforward surgical case, such as a hernia repair, to a highly complex Intensive Care Unit stay for a patient that may have multiple complex conditions and complications.”

“For example, if a patient is admitted for treatment of anaemia, we are looking for specific documentation on the type of anaemia i.e. iron deficiency anaemia or acute blood loss anaemia as each is coded and funded differently.”

The Australian Coding Standards provides a list of more than 200 rules on how conditions and procedures are to be coded, which clinical coders like Juliette, must interpret and apply to a range of different health care situations.

“The ICD codes form part of the data collection submitted to the Department of Health each month and provides the basis for the funding of acute admissions,” says Juliette.

Coded data is also used for research, identifying epidemiological patterns and disease trends, and also used in workforce and facility planning.

Considering a career change? Become a Health Information Manager

Studying a degree in Health Information Management can provide you with a knowledge of the clinical and business aspects of healthcare and give you a great understanding for a career as a health information expert.  As a health information manager, you’ll have a grasp on clinical classification, data analytics, health informatics and health systems management.