GYNAECOLOGY AUDIT DATASET 2004 P

GUIDELINES ON HKCOG GYNAECOLOGY AUDIT 2004 I. Principles in coding diagnosis II. Definition of diagnosis 1. If an operation was performed on the patient, the 1. Disseminated malignancies and the primary site couldn’t be pathological diagnosis would be coded. If an operation was confirmed, the diagnosis would be coded as L2. not performed, the MOST PROBABLE clinical diagnosis 2. For diagnoses under Disorders of Menstruation, known would be coded. causes should be coded as well if found. 2. Significant changes in the diagnosis noted after the audit 3. Primary amenorrhoea should be coded as I3 and secondary form had been filled can be amended by submitting a amenorrhoea (duration of amenorrhoea more than 6 months) second audit form marked with the patient’s name, I.D. as I4 irrespective of the cause. If there was a known cause, number, date of admission, the correct diagnosis code and it should also be coded e.g. primary amenorrhoea due to remark” AMENDED FORM’ vaginal atresia should be coded as I3 and B3; secondary 3. Minor incidental finding which was asymptomatic and did not amenorrhoea due to tuberculous endometritis should be require treatment SHOULD NOT be coded. coded as I4 and D5. 4. Non-gynaecological conditions which were not related to the 4. Postmenopausal bleeding is defined as genital tract cause of admission SHOULD NOT be coded. bleeding occurred 1 year after the last menstrual period. If 5. Cases of malignancy should be denoted as ...