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 auditResults
42 case notes were reviewed.6 amendments were made to the original coding giving an amendment rate of 14.28%. However the primary diagnosis was right in 100% of cases and amendments effected secondary diagnosis and procedure codes. This related to the coder facing difficulty extracting relevant information from the notes with particular problem areas being poor handwriting making notes illegible at times, information in notes being in a random order and occasional entry of conflicting information.Conclusion
An amendment rate of 14.28% to initial coding is high and can have significant implications with regards to clinical governance and evaluation of a patient’s clinical care and comparison of outcomes. It also adversely effects epidemiology data and can have an adverse impact on the trusts finances. Main areas contributing to coding errors were illegible writing, random order of filing information and conflicting data entry. Moving on to electronic case notes might be the way forward in effectively addressing this issue which has profound implications on patient care.