Documentation and coding of medical records in a tertiary care center: a pilot study

Abstract

BACKGROUNDSince the medical record is the major source of health information, it is necessary to maintain accurate, comprehensive and properly coded patient data. We reviewed 300 medical records from patients at King Faisal Specialist Hospital and Research Center, representing four departments (medicine, surgery, pediatrics and obstetrics and gynecology).METHODSThe records were audited following the guidelines of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for accuracy and completeness of documentation and coding of primary and secondary diagnoses and procedures performed.RESULTSOf 1051 items abstracted, 876 (83.3%) were accurately documented, 41 (3.9%) were inaccurately documented, and 134 (12.7%) were not documented. Of the items abstracted, 736 (70%) were assigned a correct code, 110 (10.5%) were assigned an incorrect code, and 205 (19.5%) were not coded. More items classified as accurately documented were coded correctly (71.1%) than items inaccurately documented (49.7%) (P<0.0001). The difference in comprehensiveness of documentation, which reflects physician performance, was not statistically significant among the four departments (P value <0.234). The difference in the accuracy of coding, which reflects coder performance, was statistically significant (P value < 0.036).CONCLUSIONSOnly 60% of the audited records met the benchmark for good quality medical records with regards to documentation and coding. A positive correlation between the accurate documentation and correct coding was noted, which supports the conclusion that high quality documentation enhances coding accuracy. These data, although encouraging, suggest room for improvement, which can be achieved through the collaboration of clinicians, who have extensive clinical experience, and coding professionals, who have comprehensive classification system expertise.

Effective factors on accuracy of principal diagnosis coding based on International Classification of Diseases, the 10th revision (ICD-10)

“…In a study, a 21% increase in coding accuracy was found due to high-quality documentation (Farhan et al, 2005). Further, it has been shown that a computerized database significantly improved the accuracy and completeness of documentation and diagnostic coding (van Walraven & Demers, 2001).…”

Suggested Minimum Data Set for Speech Therapy Centers Affiliated to Tabriz University of Medical Sciences

“…The quality of the case studies, research, statistics, scientific information, depending on the quality of content that is serving the documentary record. These qualities, often in terms of being a true complete availability, timely and legibility described ( 6 ). The new medicine, producing large amounts of data looking, but always there is a deep gap between data collection to understand and interpret the data available from the other side, they are bulky and confusing ( 7 , 8 ).…”

Quality of documentation of electronic medical information systems at primary health care units in Alexandria, Egypt

“…In primary health care (PHC), e-records have uses beyond simply retrieval of patient information; for example, warnings of allergies and drug interactions, developing management protocols for chronic illness, generating pre-appointment reminders and establishing communication links between different levels of care [2,3]. E-records are assumed to improve the quality of documentation over paper-based medical records via automatic reminders to health-care professionals of important data that are missing [4,5]. Some authors, however, have warned that inadequate computer skills or lack of training of health professionals together with limitations in erecords software could result in the data in e-records being truncated compared with paper-based records [6].…”