Abstract:Clinical coding plays a vital role in ensuring accuracy of data used for clinical governance and statistical comparison of health outcomes. This audit looked at the quality and depth of the coding by the clinical coder compared to what is documented by the clinical staff in the patient record.
Methods
Retrospective review of obstetric case notes. All patients admitted under a randomly selected consultant in the month of April 2013 were included in the audit
Results
42 case notes were reviewed.6 amendments … Show more
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