When reviewing clinical documents, you may identify a problem documented in the letter that appears to match a condition already recorded in the patient's history.
However, the condition may be described using a different code, a more specific code, or an alternative clinical term.
The goal is to determine whether the problem in the letter represents:
The same existing problem is already recorded in the patient's history, requiring the code to be updated or linked.
A more specific version of an existing problem.
A completely new occurrence of the condition that should be recorded separately.
Investigating Before Linking
Never assume that similar codes automatically represent the same problem instance.
Before linking a problem, investigate the available evidence, including:
Dates of diagnosis and treatment
Timeline described in the letter
Previous consultations
Hospital admissions and discharge summaries
Clinical context surrounding the event
Resolution status of the existing problem
The objective is to determine whether both records refer to the same clinical event.
Example 1: Same Instance of a Condition
Existing Record: Pneumonia coded 10 days ago.
Letter states: Community-acquired pneumonia diagnosed one week ago.
Assessment: The timing and context strongly suggest both records refer to the same episode of pneumonia.
Action: Link to the existing problem and update to the more specific code if appropriate.
Example 2: Different Instance of a Condition
Existing Record: Pneumonia coded one year ago.
Letter states: Community-acquired pneumonia diagnosed last week.
Assessment: Although the conditions are clinically similar, the timing indicates these are separate episodes of pneumonia.
Action: Create a new problem entry rather than linking to the historical pneumonia record.
👩🏻⚖️ Making the judgement call: Linking problems often requires clinical investigation and judgement rather than simple code matching.
Questions to consider when deciding to link or not link a problem:
Do the dates align?
Does the clinical context match?
Is the letter describing the same episode of illness?
Has the original condition already been resolved?
Is the new code simply a more specific description of the existing problem?
Is there evidence that this represents a recurrence or entirely new occurrence?
If the available evidence indicates that the letter and the historical record refer to the same clinical event, the existing problem can be linked and, where appropriate, updated to a more specific code.
If the evidence suggests a separate occurrence of the condition, a new problem should be recorded instead.