Improving the quality of clinical coding and payments through student doctor–coder collaboration in a tertiary haematology department

Abdulla, Suha; Simon, Natalie; Woodhams, Kelvin; Hayman, Carla; Oumar, Mohamed; Howroyd, Lucy Rose; Sethi, G

doi:10.1136/bmjoq-2019-000723

Cited by 8 publications

(9 citation statements)

References 12 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Furthermore, due to their legal value, especially as more litigation claims are increasing on annual basis among surgical departments [ 26 ], administrations of concerned bodies often push for more documentation at the expense of proper healthcare delivery [ 25 ]. Moreover, proper documentation is essential as it is a cornerstone in the quality development of hospital services and long-term patient-oriented treatment plans and influences revenue [ 27 ]. Nevertheless, the value of documentation throughout healthcare is understudied, as there are no significant efforts delineating the impact of proper documentation on patient care [ 25 ].…”

Section: Discussionmentioning

confidence: 99%

Improving the Quality of Medical Documentation in Orthopedic Surgical Notes Using the Surgical Tool for Auditing Records (STAR) Score

Mafrachi¹,

Al-Ani²,

Debei³

et al. 2021

Cureus

View full text Add to dashboard Cite

Aims Due to the significant value held by medical records in terms of influencing patient care and medico-legal cases, this study aimed to investigate the quality of surgical notes and their improvement through periodic auditing during a six-year period at a major tertiary hospital. Methodology This study retrospectively evaluated surgical records of patients undergoing elective orthopedic surgeries at Jordan University Hospital from 2016 to 2021 using the Surgical Tool for Auditing Records (STAR) validated questionnaire. This questionnaire is composed of six distinct sections aimed to quantify the quality of medical records and demonstrate their associated deficiencies. Pre- and post-audit STAR scores were analyzed using the two independent sample t-test on Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp. Armonk, NY). Results A total of 454 records were randomly selected and evaluated using the STAR questionnaire. There was an overall significant trend of improvement in the quality of records in all evaluated years compared to the 2016 baseline. The most pronounced improvements were in the records of 2021 as compared to the 2016 baseline (97.4 ± 0.7 vs. 94.3 ± 1.6; p:<0.05), in which the Initial Clerking, Subsequent Entries, and Operative Record domains had the most significant magnitude of change. The Consent and Anesthesia domains plateaued over the study’s period in terms of overall quality. The most improved STAR domain was the Discharge Summary domain, in which four subsections (follow-up, diagnosis, complications, and medications on discharge) had significant STAR score increases (all; p:<0.05). Conclusion Our study implies that simple measures, including personnel education and training and periodic auditing, are effective measures in increasing the quality of surgical records. High-quality medical records need to be sustained and continuously improved, as they contribute to better health care, promote research, and contribute to economic gains through cost-effective practices.

show abstract

Section: Discussionmentioning

confidence: 99%

Improving the Quality of Medical Documentation in Orthopedic Surgical Notes Using the Surgical Tool for Auditing Records (STAR) Score

Mafrachi¹,

Al-Ani²,

Debei³

et al. 2021

Cureus

View full text Add to dashboard Cite

show abstract

“…An explanation may be that hospital coding did not completely document relevant comorbidities for these patients. Evidence of incomplete capture of comorbidities using hospital admission and discharge coding data has been documented by other authors throughout the world [ 30 , 31 ].…”

Section: Discussionmentioning

confidence: 99%

Management of high and low risk malignant polyps: a population‐wide analysis

et al. 2022

View full text Add to dashboard Cite

Aim The management of malignant polyps is a treatment dilemma in selecting between polypectomy and colorectal resection. To assist clinicians, guidelines have been developed by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) to provide treatment recommendations. Methods This study compared management strategy based on the ACPGBI risk categorization for malignant polyps. Univariable and multivariable statistical analysis was undertaken to assess the factors predicting management strategy. A population‐wide analysis was performed of 1646 malignant polyps and the factors that predicted their management strategy, from Queensland, Australia, from 2011 to 2019. Results Overall, 31.55% of patients with very low or low risk disease proceeded to resection. Of those with high or very high risk disease, 36.69% did not proceed to resection. In very low and low risk polyps, age (P = 0.003) and polyp location (P < 0.001) were significantly different between the colorectal resection group and the polypectomy alone group. In those with very high or high risk polyps age (P < 0.001), type of facility (public or private) for the colonoscopy (P = 0.037), right colonic polyps compared to left colonic polyps (P = 0.015) and rectal polyps (P < 0.001) and mismatch repair mutations present (P = 0.027) were predictive of resection in high risk disease using a multivariable model. Conclusion Over 30% of patients with very low and low risk malignant polyps proceeded to resection, against the advice of guidelines. Furthermore, over 35% of patients with very high or high risk malignant polyps did not proceed to resection. Education strategies may improve management decision choices. Furthermore, improvements in data collation will improve the understanding of management choices in the future.

show abstract

“…To assure the accuracy of clinical documentation, the proposed interprofessional collaborative educational sessions, which are in place in some health services were reported to be beneficial. Previous studies also reported that improved clinician-coder collaboration is beneficial ( 30 ) as it can improve the quality of coding ( 47 ).…”

Section: Discussionmentioning

confidence: 99%

Clinical Coders' Perspectives on Pressure Injury Coding in Acute Care Services in Victoria, Australia

Weller

Turnour

Connelly

et al. 2022

Front. Public Health

View full text Add to dashboard Cite

Pressure injuries (PIs) substantively impact quality of care during hospital stays, although only when they are severe or acquired as a result of the hospital stay are they reported as quality indicators. Globally, researchers have repeatedly highlighted the need to invest more in quality improvement, risk assessment, prevention, early detection, and care for PI to avoid the higher costs associated with treatment of PI. Coders' perspectives on quality assurance of the clinical coded PI data have never been investigated. This study aimed to explore challenges that hospital coders face in accurately coding and reporting PI data and subsequently, explore reasons why data sources may vary in their reporting of PI data. This article is based upon data collected as part of a multi-phase collaborative project to build capacity for optimizing PI prevention across Monash Partners health services. We have conducted 16 semi-structured phone interviews with clinical coders recruited from four participating health services located in Melbourne, Australia. One of the main findings was that hospital coders often lacked vital information in clinicians' records needed to code PI and report quality indicators accurately and highlighted the need for quality improvement processes for PI clinical documentation. Nursing documentation improvement is a vital component of the complex capacity building programs on PI prevention in acute care services and is relied on by coders. Coders reported the benefit of inter-professional collaborative workshops, where nurses and coders shared their perspectives. Collaborative workshops had the potential to improve coders' knowledge of PI classification and clinicians' understanding of what information should be included when documenting PI in the medical notes. Our findings identified three methods of quality assurance were important to coders to ensure accuracy of PI reporting: (1) training prior to initiation of coding activity and (2) continued education, and (3) audit and feedback communication about how to handle specific complex cases and complex documentation. From a behavioral perspective, most of the coders reported confidence in their own abilities and were open to changes in coding standards. Transitioning from paper-based to electronic records highlighted the need to improve training of both clinicians and coders.

show abstract

Improving the quality of clinical coding and payments through student doctor–coder collaboration in a tertiary haematology department

Cited by 8 publications

References 12 publications

Improving the Quality of Medical Documentation in Orthopedic Surgical Notes Using the Surgical Tool for Auditing Records (STAR) Score

Improving the Quality of Medical Documentation in Orthopedic Surgical Notes Using the Surgical Tool for Auditing Records (STAR) Score

Management of high and low risk malignant polyps: a population‐wide analysis

Clinical Coders' Perspectives on Pressure Injury Coding in Acute Care Services in Victoria, Australia

Contact Info

Product

Resources

About