The Quality of Medical Record Documentation and External Cause of Fall Injury Coding in a Tertiary Teaching Hospital

Abstract

This paper reviews the documentation and coding of External causes of admitted fall cases in a major hospital. Intensive analysis of a random selection of 100 medical records included blind re-coding in the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian Modification (ICD-10-AM), Fifth Edition for External causes to ascertain whether: (i) the medical records contained sufficient information for assignment of specific External cause codes; and (ii) the most appropriate External cause codes were assigned per available documentation. Comparison of the hospital data with the state-wide Victorian Admitted Episodes Database (VAED) data on frequency of use of External cause codes revealed that the index hospital, a major trauma centre, treated comparatively more falls involving steps, stairs and ladders. The hospital sample reflected lower usage, than state-wide, of unspecified External cause codes and Other specified activity codes; otherwise, there was similarity in External cause coding. A comparison of researcher and hospital codes for the falls study sample revealed differences. The ambulance report was identified as the best source of External cause information; only 50% of hospital medical records contained sufficient information for specific code assignation for all three External cause codes, mechanism of injury, place of occurrence and activity at time of injury. Whilst all medical records contained mechanism of falls injury information, 16% contained insufficient details, indicating a deficiency in medical record documentation to underpin external cause coding. This was compounded by flaws in the ICD-10-AM classification.

Current Clinical Coding Practices and Implementation of ICD-10 in Africa: A Survey of Nigerian Hospitals

“…The majority (74%) of these coders spent more than four hours on clinical coding duties as they had to attend to other duties of managing health information such as data entry (27%), documentation (21%) and quality assurance (13%). Our findings coincide with other studies that clinical coders do engage in other duties [43]. Even, managers of clinical coding units recommended that engaging in a variety of role behaviours will improve clinical coding practice [47].…”

“…Similarly, clinical coding practices at tertiary healthcare facilities were considerably efficient except that automation (8.8%) and adequacy of clinical coders (13.5%) were lacking. These findings agree with the report by Cunningham et al [43] where coding specificity of a hospital stood it out in the comity of healthcare industry.…”

“…The two major challenges border on clinical documentation and health data quality as it affects clinical coding. The quality of health records and clinical documentation directly affects the quality of clinical coding [43]. Cunningham et al [43] also reported insufficient information for specific code assignment.…”

“…The quality of health records and clinical documentation directly affects the quality of clinical coding [43]. Cunningham et al [43] also reported insufficient information for specific code assignment. Similarly, documentation issues have been of primary concern for coding quality [44] and it has been suboptimal in developing nations such as Nigeria [11] where discharge summary is reported to be grossly underutilized.…”

“…Even, managers of clinical coding units recommended that engaging in a variety of role behaviours will improve clinical coding practice [47]. As it is obtainable in developed nations [43], the Nigerian healthcare systems need special education in clinical coding as advanced by researchers [47][48] in order to have a thorough understanding of ICD-10 and the fact that ICD-10 would require more time for clinical coding processes [50]. Participants in this study suggested ways to improve clinical coding practices in Nigeria.…”