Topic

V1

V2

Explanation

Virtual encounter status

✅

✅

If a virtual (telemedicine, or video) consultation is detected, we will add a virtual visit status.

Inferred encounter status (department + letter type)

✅

✅
Coded by Mailroom

Based on the combination of department and letter type, we will trigger a predefined set of encounter statuses.

Confirmed diagnosis

✅

✅

We only will code a confirmed diagnosis mentioned in the letter. If the code detected by the bot is present in patient’s history, we will remove the existing diagnosis

Major procedures

✅

✅

Major procedures, such as MRI, CT, etc. will be coded

Minor procedures

✅

❌

Some procedures deemed minor, such as wound dressing, or insertion of cannula will not be coded in this version in line with the AI minimisation plan.

Biopsy

❌

✅

Biopsy will be coded as procedure with a body part or with a name (e.g. Cold biopsy).

minor Sign and symptoms

❓

❌

In line, with the new policy of AI minimisation, we will not code minor signs and symptoms such as nausea, headache, etc. We also, do not code self reported findings such as pain.

Major signs and symptoms

❓

✅

We will code major signs and symptoms that are borderline diagnosis, such as migraine or seizure.

Lives alone

✅

✅

If the letter explicitly mentions that the patient lives alone, we will code it. We do not code any other living arrangements.

Frailty

✅

✅

If the letter mentions frailty, or frailty index, we will code them. We also code fragility fracture that is a result of frailty. Falls also is in this category.

Mobility

✅

✅

Mention of wheelchair, being bed bound, and in general anything related to dependent mobility will be coded. We will not code anything related to assisted mobility such as a walking stick or crutches.

Smoking

✅

✅

If the letter mentions anything related to smoking status (e.g. current smoker, ex-smoker, non-smoker, and never smoked), we will code them. For the current smoker, we will look and extract the number of cigarettes/e-cigarettes and will provide a code that reflects this number.

Drinking

✅

✅

If the letter contains a drinking status (absence or presence) we will provide an appropriate code.

Drug usage

✅

✅

If the patient explicitly mentioned to use drugs, we will extract and code this.

Safeguarding issues

✅

✅

Anything safeguarding related, such a bullying, adoption, child in care, any sort of assault, etc. will be picked up.

Mental health consequences (e.g. suicide)

✅

✅

Other safeguarding issues that are mental health related like suicidal thoughts or attempt are covered

Other social / personal issues

✅

❌

In line with AI minimisation, we will not code anything social and personal that does not directly impact patient care such as employment.

Common blood tests

✅

✅

Common blood tests that GPs commonly order to assess overall health, diagnose conditions, and monitor ongoing treatments are covered. Common blood tests often either have a numerical value or in some cases such as HIV they have a qualitative value.

Specialised blood tests

❌

❌

We do not code specialised blood tests that could be performed only in hospitals and the results could also be interpreted by a specialist.

Urine tests

✅

❌

As part of AI minimisation, we have stopped coding any type of urine tests

General values

✅

✅

Examinations that contain a value such as BP, heart rate, weight, and etc. are covered. Result of procedures such as t-score, or assessments such as PHQ-9 are also covered under general values

Histopathology

✅

✅

The result of biopsies, if present, are extracted and coded.