Data Quality — Monitoring the Accuracy of Clinical Information

The key drivers of change to clinical coding practice are identified and examined, and a major shift is predicted. The traditional purposes of the coding function have been the provision of data for research and epidemiology, in morbidity data reporting and, latterly, for casemix-based funding. It is contended that, as the development of electronic health records progresses, the need for an embedded nomenclature will force major change in clinical coding practice. Clinical coders must become expert in information technology and analysis, change their work practices, and become an integral part of the clinical team.

Section: Poor Medical Record Documentationmentioning

confidence: 84%

“…Other studies have identified similar problems faced by clinical coders, such as in the identification of principal and associated diagnoses, inconsistent or unclear documentation, and ambiguity of medical record content (Chisholm et al 1994;Donoghue 1992;Callen et al 1997).…”

Section: Poor Medical Record Documentationmentioning

confidence: 95%

Predicting the Influence of the Electronic Health Record on Clinical Coding Practice in Hospitals

Robinson

Shepheard

2004

“…In 1994 and 2002 Similarly, in coding audits conducted by Chisholm et al (1994), Donoghue (1992) and Callen et al (1997), identification of principal and associated diagnoses, inconsistent or unclear documentation, and ambiguity of medical record content were found to be the main causes of coding error and to contribute to other leading sources of error. Therefore, the primary documentation factors affecting coding quality have changed little during the past decade.…”

Section: Findings Documentation Factors Affecting Coding Qualitymentioning

confidence: 99%

The Effects on Clinical Coding of the Critical Pathway Recording Methodology

Cameron

Robinson²

2004

A two-stage study aimed to identify the effects of the critical pathway recording methodology on clinical coding practice and to determine coders' participation in pathway development. Critical pathways were found to be in widespread use, with low coder participation in pathway development and poor education on pathway data extraction. Coders favoured the traditional medical record format; private sector coders predominated amongst those who preferred to code from records containing pathways because of poor private sector clinical documentation. The documentation factors that most affected the clinical coding process were consistent with those identified previously and were primarily doctor-related.

Looking to CQI for Improvements in Clinical Documentation and Coding

Callen

Meehan

Tomornsak

1997

The following paper examines how the philosophy of Continuous Quality Improvement (CQI) can be used to improve the quality of clinical documentation and coding. The philosophical basis of CQI and its application in the healthcare environment is outlined. Health information managers need to explore inventive ways of solving the problem of inadequate clinical documentation and high coding error rates, particularly in light of the current casemix-based funding environment.