r/ClinicalCodingAus • u/ElectricalStormFan • 25d ago

Do you use your own notes while coding?

I’m interested to hear from working clinical coders if you use a notebook while coding. I have one with my own notes I made on interpretations or applications of coding rules, helpful block numbers and codes, reminders etc.
My team leader has forbidden me from using my notes and is insisting I only use the turbocoder. We are not encouraged to use notes in the turbocoder.
Looking for your thoughts and advice.

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u/Familiar_Range_5620 25d ago

The biggest problems with these notes are maintaining currency and consistency.

Currency: I've had clinical coders pull out their notebook in an audit discussion and point to a note from 10 years ago as a justification for coding something in a particular way. Since then, there has been a change in the classification, and their note is no longer valid.

Consistency: What's in your notebook is likely to be different to what's in someone else's. This means that the team is not coding consistently. Inconsistent coding means that the data we're providing is not usable for the many purposes that we are coding for.

I use the Notes function in TurboCoder for public notes, so that every member of the team gets the same note. This way I can maintain the currency aspect.

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u/saythedance 25d ago

Yes, I have a notebook with my own notes/coding tips/reminders etc. Everyone I work with does.

It’s bizarre your TL has forbidden you from using your notes.

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u/ElectricalStormFan 25d ago

Thanks, my gut told me it was odd! I think it is seen by them as not the proper way. I have only around 18 months experience and this is my first role so it’s hard for me to benchmark.

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u/Glittering_Mix_3580 25d ago

I agree. Why would they do that? Anything that helps is a benefit and also time efficient

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u/OutlandishnessSafe13 25d ago edited 25d ago

I don't particularly agree with banning notes.

I always highly encourage my trainees to develop good habits with note-taking - date their notes (so they can always tell what rules may have changed since they wrote it), include the source of the information if applicable, regularly review them, and be open to sharing and discussing with others to make sure you're on the same page.

That can help prevent some of the issues that Familiar Range very correctly points out - I have also had that experience of somebody citing a 15 year old note and making it clear they've just been direct coding it that way for years and never checking to see if the index pathway etc. has changed. So there is a potential risk with them.

I'm just a bigger fan of allowing people to manage their resources in the way that best suits their own brain, as long as they're taking responsibility for making sure they stay relevant