HIMAA Conference 16/10/09 www.ifhro.or www.ifhro.or g g The Relationship between Health The Relationship between Health Record Documentation and Record Documentation and Clinical Coding Clinical Coding Lorraine Nicholson President of IFHRO (International Federation of Health Records Organisations) & Independent Health Records Consultant Co-Author: Sue Walker Director, National Centre for Health Information Research and Training, Australia HIMAA Conference, Perth, Australia 16 th October 2009
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The Relationship between Health Record Documentation and Clinical Coding
The Relationship between Health Record Documentation and Clinical Coding. Lorraine Nicholson President of IFHRO (International Federation of Health Records Organisations) & Independent Health Records Consultant Co-Author: Sue Walker - PowerPoint PPT Presentation
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The Relationship between Health Record The Relationship between Health Record Documentation and Clinical CodingDocumentation 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
National EHR Development in National EHR Development in EnglandEngland
National EHR development in England is the responsibility of NPfIT (£6.2 billion)
The NHS Care Records Service will provide 60 million NHS patients with an individual electronic NHS Care Record providing details of key treatments and care within the health service and/or the social care sector
There are two principal components to the electronic patient record programme for hospitals in England
1. The Summary Care Record (held nationally) 2. The Detailed Care Record (held locally).
Importance of Standards for Electronic Importance of Standards for Electronic Health Record DevelopmentHealth Record Development
The implementation of EHR’s in the NHS significantly increases the importance of structured records & this applies to all EHR systems wherever they are implemented around the world
With the development of EHR’s there is an urgent need to standardise the structure & content of clinical information recorded & communicated through the Health Record
Standards to EnsureStandards to Ensure Safer & More Safer & More Efficient & Effective CareEfficient & Effective Care
Structure & content standards are crucial to ensure that clinical information can be consistently stored, retrieved & shared between information systems
The standards must therefore be based on professional agreement that reflects best clinical practice
Standards must be incorporated into information systems by skilled IT professionals
Patients must also be involved at all stages of standards development
The Main Benefit of Structure & The Main Benefit of Structure & Content Standards in EHR Content Standards in EHR
SystemsSystems
Clinical information in electronic health records will be recorded once, and made available when and where required, thus improving efficiency and saving time
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