When Accurx Scribe generates your consultation note, it now also suggests relevant SNOMED problem codes based on the consultation content.
You can review these suggestions, add or remove codes, and save them directly back to the patient record's problem field in your clinical system, all without leaving Scribe.
Codes are only ever saved when you choose to save them. Nothing is coded automatically: every code requires you to review and accept it first.
Who can use it?
Available for organisations using EMIS and SystmOne
How to add SNOMED problem codes to a consultation
Start your consultation and generate the note in Scribe as usual.
Scroll to the bottom of the note. Suggested SNOMED codes appear in the Codes section, with the most relevant suggestions listed first. Each code shows its SNOMED concept ID and description đ
Select the codes you want. Click a suggested code to add it, use the magnifying glass to view details, or use Search codes to look up any code that wasn't suggested. Remove a code at any time with the X next to it.
Click 'save to record' when you are ready. If this button is clicked too quickly without edits being made to the note, you will be reminded to review the notes before transferring to the record.
Confirming the SNOMED problem code transfer and setting code details
Before any SNOMED codes are saved, an additional confirmation screen displays the patient's details, the clinical system the note will be saved to, and the full list of problem codes being added to the record.
For each problem code, you can set the significance to Major or Minor and optionally an expected duration. The codes are saved into the problem field of your medical record.
Note: The significance defaults to "significant/major" unless changed; if a user does not select a duration, it will default to "indefinite".
â ď¸ Review codes before transfer: Codes saved from Scribe go directly into the record. It is your responsibility to review the codes carefully before saving.
Once you click Save to record, the note and codes are written back to the patient record.
Duplicate codes
Scribe checks the codes you've selected against the problems already on the patient's record.
If a code is already on the problem list, it's flagged as "Already in record" on the confirmation screen so you can review to make sure it is appropriate to add again as a new problem đ
Where the codes appear in your clinical system
After saving, the codes appear in the problem list of the patient record, linked to the consultation.
In EMIS, the codes appear under Active Problems with the significance (Significant/Minor) and duration you selected đ
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In SystmOne, the codes appear under Major or Minor Active Problems đ
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Tips
Every code requires your explicit acceptance. Scribe never automatically saves codes to the record.
You can use Search codes to add any supported code that wasn't suggested.
Codes are saved as new problems in the problem field only; they are not linked to existing problems and are not written to other headings.
Always review the note and codes before transferring.
Frequently Asked Questions
Is this a medical device?
Is this a medical device?
Yes - suggested coding forms part of Tandemâs Class IIa medical device:
GMDN Code - 61087 Clinical management support software
Risk Classification - Class IIa
Manufacturer - TANDEM HEALTH GLOBAL LIMITED
Do I have to pay for SNOMED problem coding?
Do I have to pay for SNOMED problem coding?
Integrated SNOMED coding (codes that can be saved directly back into the record from Scribe) will only be available to customers on a paid Scribe contract.
Suggested SNOMED codes (which are surfaced but cannot be saved directly back to the record from Scribe) will be available on our free trial and Lite offering.
Which SNOMED codes are supported?
Which SNOMED codes are supported?
Currently a list of around 62k SNOMED codes are supported for Problem coding in Accurx Scribe. These are some of the most frequently used SNOMED codes, selected from the following SNOMED categories that are likely to form a large part of the patient Problem list:
Disorder
Situation
Procedure
Finding
Regime/therapy
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Why do you not support every code? A SNOMED code I want to use is not supported - how can I get it added?
Why do you not support every code? A SNOMED code I want to use is not supported - how can I get it added?
Whilst we will look to increase the number of codes we support, we currently cannot support every SNOMED code from the library, as:
Some code categories would not be applicable or appropriate to save to the problem field in the medical record
Certain codes require additional, validated information to be added - Observational codes - and so these (apart from the current supported 10 from within Accurx Scribe) are not supported for individual selection
If there are any codes not present that you would like incorporated please reach out and let us know.
What âQualifierâ information can I add to a SNOMED code? Can I link to previous problem codes or create a âreviewâ of a previous problem code?
What âQualifierâ information can I add to a SNOMED code? Can I link to previous problem codes or create a âreviewâ of a previous problem code?
When searching for, choosing and saving a SNOMED code to the record in Accurx Scribe, they currently save to the âProblemâ section for the patient, as a âNewâ problem.
You can select the duration you want for the problem, and also whether the problem is âmajor / significantâ or âminorâ.
If you need to add any additional qualifier information, e.g. laterality, additional text, or if you need to capture a âreviewâ of a pre-existing problem, then you can save manually to the record instead of through the coding feature in Accurx Scribe.
What does âalready in recordâ mean?
What does âalready in recordâ mean?
When saving to the medical record, if a code is detected in the patient's âactiveâ problem list, or their âsignificant pastâ problems, there will be a prompt to review this code to see if saving it as a new problem code for that patient. If inappropriate to include following review, this code can be removed before saving to record.
Can I save non-âproblemâ codes to the record?
Can I save non-âproblemâ codes to the record?
The current release focuses on âproblemâ codes, but we will be looking to enable saving to other parts of the consultation or record in future iterations.
Can I save multiple problem codes in one consultation?
Can I save multiple problem codes in one consultation?
Yes â if you add more than one problem code, in EMIS they will be saved as additional problem codes within the same consultation when saved back to the record.
In SystmOne, added problem codes are all listed in either the Major or Minor active problems section according to classification upon saving.
Where can I access the clinical safety documentation for this feature?
Where can I access the clinical safety documentation for this feature?
Our DCB0129 clinical safety documentation can be found on our Trust Centre here:
If you still have any questions or concerns, feel free to chat with us using the green message bubble in the bottom right-hand corner of this page. đ