Rechecks1

(Version: 07/12/05)

 

Definition:   A disorder or finding is considered a recheck when that disorder or finding is present on a subsequent visit and is to be considered the same episode of disease as in the previous visit.  A disorder is not considered a recheck when it reoccurs independently of a previous episode of the disease.

Do not confuse the fact that the animal is coming to the hospital for a “recheck” appointment type with the rechecking of a course of a disease or post operative outcome of the patient.  

 

Introduction:  ‘Recheck” in this guideline implies that the disease or finding is focused on a past finding or event.  The approach taken is dependent upon the type of recheck performed. 

 

Note:   In order to simplify the data entry process, VMDB will utilize a ‘recheck’ field to designate that a disorder or finding is to be considered either an initial observation or a recheck.  The recheck SNOMED concept is not used at this time.  In addition, the ‘recheck’ or ‘initial’ designation is to be applied at the concept level, not the visit level; see Example Case 1.  (See the VMDB Transmission Guidelines).

 

Attributes such as finding sites need not be marked as rechecks if the associated disorder has been marked as a recheck.  (In the example below VMDB will assume this is a recheck of an already diagnosed cataract).

Example: 

·       Cataract (disorder) – Recheck

o      Finding site (attribute) – initial

o      Left eye (body structure) -  initial

 

 

 

 

 

The same rule may not necessarily apply with associated morphology (also see examples in Case 4 and Case 5).

Example:         (Initial visit to hospital):      

·       Benign neoplasm of skin of neck (disorder) – Initial

 

(Next visit to hospital patient has biopsy of the same neck lesion.   It is the same tumor but we now have a tumor differentiation):

·       Benign neoplasm of skin of neck (disorder) – Recheck

o      Associated morphology (attribute)

o      Lipoma (morphologic abnormality) - Initial              

 

 

Root Concept:

“Surgical Follow-up (finding)” 183644000

 “General Body State Finding” 82832008

 

1.         Recheck to Evaluate the Course of a Disease, e.g. diabetes mellitus, otitis externa:

The first time a patient is diagnosed with a particular condition is considered the ‘initial’ diagnosis.   If the patient returns for a follow-up for the same on-going condition, it may considered a recheck for that diagnosis. Example:

            First Visit; Diabetes mellitus (Disorder) = Initial designate

            Second Visit; Diabetes mellitus (Disorder) = Recheck designate

The following is an example of a new problem being diagnosed (otitis externa) during a recheck evaluation.   Example:

            Diabetes mellitus (Disorder) = Recheck

            Otitis Externa (Disorder) = Initial

 

2.         Recheck to Evaluate Outcome from a Procedure (e.g. luxation repair, cataract removal, recheck surgical wound, recheck dental appliance application, see examples below for cases 2 and 3):

Use the root concept, or child of ‘Surgical Follow-up (finding)’ 83644000

Note:   This will always be considered an ‘initial’ finding each time it is used because the recheck pertains to the diagnosis/finding rather than a procedure.

Code any additional findings separately, e.g. delayed wound healing

If the patient is diagnosed as doing well, use a patient status code, any child of  ‘General Body State Finding’ 82832008

If the patient is having a problem, use the most appropriate diagnosis (e.g. Post-op wound infection, Non-union fracture). 


 

3.         Evaluation of the Functional Status of a Device (e.g. pacemaker):*

This is not an evaluation of the disorder or outcome of the previous procedure, but a procedure which evaluates the functioning of a medical implant such as a pacemaker.

Code any applicable procedure(s), e.g. ‘Electronic analysis of internal pacemaker’ 15723004

*A diagnosis or finding concept is not required.

 

 

 

Comments:

 

  1. It is not necessary to code a diagnosis for all rechecks. However, if you choose to capture the patient progress, use an appropriate child of General Body State Finding (82832008), such as ‘Progress Satisfactory’.
  2. If a diagnosis is listed, Do Not Link the rechecked procedure concept to the diagnosis or finding.   Currently, there is no standard method for doing so and still ensure appropriate data retrievals.
  3. Do Not use the Post-Operative Status concept as a finding or disorder.

 

 

Examples:

 

Case 1:  Benign neoplasm skin of chest

A patient is initially diagnosed with a benign neoplasm of the skin of the chest.  Upon follow-up a biopsy is done and the same mass is now confirmed as a fibroma.

 

First Visit:

Benign Neoplasm of the Skin of Chest (Disorder) 92352002 = Initial

Second Visit:

Benign Neoplasm of the Skin of Chest (Disorder) 92352002  = Recheck

·       Associated morphology (attribute) 116676008

·       Fibroma (morphologic abnormality) 112682009 = Initial

Case 2:  Follow-up after Cataract removal

Patient had cataracts; had cataract removal with intraocular lens implant.  Patient is doing well.

 

Surgical Follow-up (finding) 183644000 = Initial

 

Progress Satisfactory (finding) 281013003 = Initial

 

Ophthalmic Examination and Evaluation Follow-up (procedure) 66902005 *

 

*this is a procedure, so needs no initial vs recheck designation.

 

 

 

 

Case 3: Post-surgical visit - cranial cruciate ligament rupture repair

Patient continues to be lame and now has a wound infection.

 

Surgical Follow-up (finding) 183644000 = Initial

Limping (finding) 16973004 = Recheck

Postoperative Wound Infection (disorder) 58126003

 

 

Case 4:   Clinician wrote skin mass on initial visit; upon second visit patient had biopsy of same mass, now with confirmation of both malignancy and morphology.

First Visit:

Mass of skin (finding) 297960002 = Initial

Second Visit:

Malignant neoplasm of skin (disorder) 372130007 = Recheck

·       Associated morphology (attribute) 116676008

·       Fibrosarcoma (morphologic abnormality) 53654007 = Initial

Case 5:  Clinician wrote skin tumor (or neoplasia) with confirmation of both malignancy and morphology at next visit.

First Visit:

Neoplasm of uncertain behavior of skin (disorder) 95087004 = Initial

Second Visit:

Malignant neoplasm of skin (disorder) 372130007 = Recheck

·       Associated morphology (attribute) 116676008

·       Fibrosarcoma (morphologic abnormality) 53654007 = Initial

 

 

 

 

 

 

1Written by the VMDB Taskforce on Development of SNOMED Guidelines.  The committee wishes to recognize contributions provided by Dr. Jeff Wilcke and Dr. Penny Livesay.