2nd SEAR Conference 13/10 /09 www.ifhro.or www.ifhro.or g g IFHRO IFHRO Promoting Health Promoting Health Records Standards Records Standards Lorraine Nicholson President of IFHRO (International Federation of Health Records Organisations) 2 nd SE Asia Regional Conference, Perth, Australia 13 th October 2009
IFHRO Promoting Health Records Standards. Lorraine Nicholson President of IFHRO (International Federation of Health Records Organisations) 2 nd SE Asia Regional Conference, Perth, Australia 13 th October 2009. A Vision for IFHRO. - PowerPoint PPT Presentation
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A Vision for IFHROA Vision for IFHRO In 1948 Elsie Royle had a vision … of possible cooperation
between medical record personnel around the world and a global linkage between medical record keepers
1952 1st International Congress on Medical Records held in London 1956 Washington 1960 Edinburgh1963 Chicago
In 1968 IFHRO was formed in Stockholm16 years, 5 international congresses and thousands of letters after the idea was initially discussed at the first international meeting in London in 1952
“That one of the main objectives of the IFHRO was to work closely with WHO in the promotion and extension of expertise in health record services throughout the world, with particular emphasis an education and training”
““The Relationship between Health Record The Relationship between Health Record Documentation and Clinical Coding”Documentation and Clinical Coding”
Clinical coding is the translation of medical terminology as written by the clinician into a coded format which is nationally and internationally recognised
i.e. It is the translation into code of what has been documented by treating clinical staff
Coders should not make assumptions but should only code what is documented
The accuracy of clinical coding is dependent on the clinician recording clear and complete diagnostic and procedural information
Coding reflects the quality of the source documentation as well as the skills and
Structure of the Health RecordStructure of the Health Record
Standards for organisation & configuration of Health Records are needed so that records are structured appropriately
Records are a chronological record of important events & need to be ordered appropriately so that relevant clinical information is recorded in the right place to enable clinicians to locate it quickly & easily when required
Content and Completeness of Content and Completeness of
Documentation within the recordDocumentation within the record Content and completeness standards apply to the
format & definition of what is recorded in the agreed structure to ensure that:
Entries are legible Authors of entries are attributable Entries are dated, signed and timed Amendments are made transparently Entries are made contemporaneously whenever possible but
as soon as possible after the event/encounter There is limited use of abbreviations and jargon Personal or subjective statements are not recorded There is no documentation of value judgements and
NHS Standards (England)NHS Standards (England) The Health Informatics Unit at the Royal College of
Physicians (RCP) in London has coordinated the development and piloting of nationally agreed standards for the structure and content of Health Records that have been agreed for all hospital specialties
The project was funded by NHS Connecting for Health and the standards were ‘signed off’ in April 2008 by the Academy of Medical Royal Colleges
The standards were passed as fit for purpose Psychiatry and Paediatrics - although the information
that they require is different from and additional to that covered by the standardised headings, the requirements for these specialties can be accommodated within the proposed standards structure
Benefits of Standards for HIM’s & Benefits of Standards for HIM’s & CodersCoders
Improves HIM’s & Coders ability to abstract comprehensive and relevant clinical information on which to assign the most complete and accurate set of codes to describe the clinical encounter
ICD-10 contains recommended format for medical certificate of cause of death but many of the mortality coding rules have been developed to address issues caused by inadequate documentation of cases
Instructions for morbidity coding have been developed to manage poor documentation
Having standards for record structure and content would go some way to addressing poor documentation before it becomes a coding problem
Availability of standards for Health Records (& potentially other source documents, such as death certificates) for use internationally would assist with the provision of high quality coded data
Most countries with well-developed health information systems already have their own standards
Small and developing countries in which there are few trained Health Record professionals may not have access to such standards
The authors of this paper suggest that a discussion about the development of simple, but comprehensive, standards for source documents be considered as another means to improving coding quality around the world