Step 4

Deep Dive Review & Coding (Gold Standard)

Purpose:
Create a complete, accurate and future‑proofed clinical record system supporting safe care, efficient operations and reliable long‑term programme delivery.Scope:
This work codes all clinically significant diagnoses (not minor, self‑limiting conditions such as colds or viral illnesses).

What is done:
• Systematic chart review of notes and correspondence
• Identification and coding of all clinically significant diagnoses
• Rebuild of EMR problem lists to provide:
– Clear "at‑a‑glance" summaries
– Searchable, reliable structured data
– Clean outputs for referrals and reports

Two scope options:
• 4A — Adult GMS/DVC patients only (18+)
• 4B — All active patients including private (recommended default)

Benefits

Clinical:

• Safer, faster decision-making
• Clear summaries in every consultation
• Better referral quality

Operational:
• Reliable searches, recalls, reporting and submissionsStrategic & Financial:
• Full visibility of eligible cohorts
• Removal of hidden data leakage
• Future‑proofing for new programmes and new conditions