| Introduction: The review of medical records with the aim of assessing the quality of codes has long been conducted in different countries. Auditing medical coding, as an instructive approach, could help to review the quality of codes objectively using defined attributes, and this in turn would lead to improvement of the quality of codes.Method: The current study aimed to present a model for auditing the quality of clinical codes. The audit model was formed after reviewing other audit models, considering their strengths and weaknesses. A clear definition was presented for each quality attribute and more detailed criteria were then set for assessing the quality of codes.Results: The audit tool (based on the quality attributes included legibility, relevancy, completeness, accuracy, definition and timeliness); led to development of an audit model for assessing the quality of medical coding. Delphi technique was then used to reassure the validity of the model.Conclusion: The inclusive audit model designed could provide a reliable and valid basis for assessing the quality of codes considering more quality attributes and their clear definition. The inter-observer check suggested in the method of auditing is of particular importance to reassure the reliability of coding.Keywords: Quality, Clinical codes, Audit model, Audit tool, Data quality attributes |
- WHO. Caroline, Heick. âOverview of the Canadian Institute for Health Information and the Roadmap Initiativeâ. 2001
- Audit commission. âHospitals Must Improve Accuracy of Information about Patientsâ. 2003
- Biscuit, Duncan. âData Quality Policyâ. 2002
- Clearly, Seymour. âThe NISHA Hospitals NHS Trust/Data Quality Policyâ. 2002
- Rigby, Michael. âInformation in Practiceâ. 1998
- Shortliffe, H.Edward & et al. âMedical Informaticsâ. USA, Springer-Verlag, 2001
- Johns, L. Merida. âInformation Management for Health Professionsâ. USA, Delmar publishers, 2002
- Davis, Nadinia & Lacour Melissa. âIntroduction to Health Information Technologyâ. USA, W.B. Saunders Company, 2002
- WHO. âImproving Data Quality/A Guide for Developing Countriesâ. 2003
- Moghaddasi, Hamid. âHealth Data Processingâ. IRAN, TEHRAN, Vajehpardaz, 2009
- Statement on Consistency of Healthcare Diagnostic and Procedural Coding. Journal of AHIMA 2007.
- Lowell E. Sever. Guidelines for Conducting Birth Defects Surveillance. USA; 2004. (Available from: www.nbdpn.org).
- Lorence, D.P. Are Physicians Adequately Educated in Medical Information Practices.USA; 2002. ( Available from: www.aameda.org)
- Kelvin J., Porcheret M., Croft P. Quality of morbidity coding in general practice computerized medical records: a systematic review. 2004. (Available from:fampra.oxfordjournals.org)
- The Coding Policy and Strategy Committee. Payerâs Guide to Healthcare Diagnostic and Procedural Data Quality. Journal of AHIMA 2001.
- Bajaj Y., Crabtree J., Tucker A.G. Clinical coding: how accurately is it done? British Journal of Clinical Governance 2007;12(3):159-169.
- Department of the NAVY. Coding program standard audit.USA; 2010. (Available from: www.med.navy.mil)
- Connecting for Health. NHS Classifications Service. A Guide to the Clinical Coding Audit Methodology. 2010. (Available from: www.connectingforhealth.nhs.uk)
- Hudovsky A., Wiek-Cohen M. Implementation of Hospital Clinical Coding Audits in the Czech Republic.UK; 2008. ( Available from: www.mzcr.cz)
- e-HIM Work Group on Benchmark Standards for Clinical Coding Performance Measurement quality subgroup. âCollecting Root Cause to Improve Coding Quality Measurement.â Journal of AHIMA 79, no.3 (March 2008): 71-75.
- Moghaddasi H. A comparative Study of quality control mechanisms of inpatients care information in American and England and designing a model for Iran [thesis]. Tehran: School of Management and Medical Information Sciences of Iran University of Medical Sciences; 2003.
- Moghaddasi H. Information quality in health care. Tehran: Vazhepardaz;2005.
- Clearly, Seymour. âData Quality Policyâ. 2001
- Orli, J. Richard. âData Quality Methodsâ. 1996
- Abdelhak Mervat. âHealth Information: Management of a Strategic Resourceâ. USA, W.B.Saunders Company, 2010
- ISO. âQuality Management Systems Requirementsâ. 2000
- Center for health information quality (CHIQ) âGuidelines for Health Information Qualityâ. 2002
- Friday, Gladys. âNisha Hospitals NHS Trust/Data Quality Policyâ. 2002
- Misset B., et al. Reliability of diagnostic coding in intensive care patients. Journal of Critical Care; 2008,12(4).
- Farzandipour, M., Sheikhtaheri, A. determination of diagnostic coding accuracy ,based on ICD-10; 2008.
- Mahmudzade Sagheb Z. Determination of coding accuracy in the training hospitals of Shiraz University of Medical Sciences [dissertation]. Tehran: School of Management and Medical Information Sciences of Iran University of Medical Sciences; 1995.
- Jordan K., Procheret M., Croft P. Quality of morbidity coding in general practice computerized medical records: a systematic review. Journal of Family Practice 2004; 21(4): 396-412.
- Dixon, J., Sanderson, C., Elliott, P. Assessment of the reproducibility of clinical coding in routinely collected hospital activity data: a study in two hospitals. UK. 1997.
- Thi Hong, T., Walker, S. McKenzie, K. The quality of injury data from hospital records in Vietnam. 2009.
- Hasan, M., Meara, R.J., Bhowmick, B.K. The quality of diagnostic coding in cerebrovasular disease. International Journal for Quality in Health Care 1995;7(4):407-10.
|
