Impact of Documentation Errors on Accuracy of Cause of Death Coding in an Educational Hospital in Southern Iran

Abstract

Accurate cause of death coding leads to organised and usable death information but there are some factors that influence documentation on death certificates and therefore affect the coding. We reviewed the role of documentation errors on the accuracy of death coding at Shahid Mohammadi Hospital (SMH), Bandar Abbas, Iran. We studied the death certificates of all deceased patients in SMH from October 2010 to March 2011. Researchers determined and coded the underlying cause of death on the death certificates according to the guidelines issued by the World Health Organization in Volume 2 of the International Statistical Classification of Diseases and Health Related Problems-10th revision (ICD-10). Necessary ICD coding rules (such as the General Principle, Rules 1–3, the modification rules and other instructions about death coding) were applied to select the underlying cause of death on each certificate. Demographic details and documentation errors were then extracted. Data were analysed with descriptive statistics and chi square tests. The accuracy rate of causes of death coding was 51.7%, demonstrating a statistically significant relationship (p=.001) with major errors but not such a relationship with minor errors. Factors that result in poor quality of Cause of Death coding in SMH are lack of coder training, documentation errors and the undesirable structure of death certificates.

Death certificates errors in academic hospital; Review of 617 cases at Komfo Anokye Teaching Hospital (KATH), Kumasi

“…Demographics of sex mortality rates in this study is in concordance with Filippatos et al (2016) and Haghighi et al (2014). Both studies documented high male mortality rate than females.…”

“…Filippatos et al (2016) had 50.7% male prevalence, slightly below that of this study. Haghighi et al (2014) recorded 62.6% male prevalence which is above that of this study. However, Antini et al (2015) and Nojilana et al (2009) recorded 59.2 and 51% female prevalence, respectively, which is antipodal to findings of the present study.…”

“…Studies conducted in South America (Antini et al, 2015), Asia (Haghighi et al, 2014) and Africa (Izegbu et al, 2006) have confirmed high incidence of inaccuracies in death certification. Contrarily, some measures have been put in place over the years to ensure accurate death certification in many countries such as USA, Scotland, Finland and Sweden (Lahti and *Corresponding author.…”

A Three-Phase Decision Model of Computer-Aided Coding for the Iranian Classification of Health Interventions (IRCHI)

“…In addition, several researchers emphasized on the necessity of using the unique language and standard terminology in medical documentation for implementing NLP based systems ( 46 - 48 ). However, in Iran, physician and other care specialists use a combination of both languages of English and Persian for clinical documentation ( 49 ). This problem the part of speech tagging makes difficult to develop the NLP-based CAC systems.…”

Medical Certificates of Cause of Death for people with intellectual disabilities: A systematic literature review

“…The most commonly reported factor is insufficient training or a lack of knowledge about completing the MCCD on the part of the certifier (Bell et al., ; Harriss et al., ; Mahdavi, Sedghi, Sadoghi, & Fard Azar, ; Rampatige et al., ). Other factors associated with the accuracy and effectiveness of MCCD are the profession of the certifier (Katsakiori et al., ; Mahdavi et al., ; McKenzie, Chen, & Walker, ), the number of causes of death reported (Antini et al., ), a lack of knowledge of the medical history of the deceased person (Katsakiori et al., ), the frequency of use of autopsy in a country (Ylijoki‐Sorensen et al., ) and multiple languages used within a country (Haghighi, Dehghani, Teshizi, & Mahmoodi, ). In addition, the frequency of the use of autopsy has seen a major decline over past decades for people regardless of disability status (Ministry of Justice ; Shojania & Burton, ), and concerning rates of poor quality autopsies have been reported (Kuijpers et al., ; NCEPOD ).…”