A review of clinical coding accuracy at University College Hospital, Ibadan, Nigeria
Abstract
Background: Clinical coding is an important aspect of health information management and the process must be accurate as mistakes in coding can lead to multiplication of errors in patient care and clinical research. Coding accuracy measures the level of agreement between the disease classification systems code(s) and the selected code(s) recorded in the discharged record by the Coder. The integrity of data from clinical coding depends fundamentally on the quality of clinical documentation, availability of discharge summary in the patient record and Coders ability. The study examine accuracy in terms of levels of agreement and including completeness of codes and factors that may contribute to error in coding. Methods: A sample of 2000 discharged patients’ health records that had been previously coded was randomly selected and re-coded by an experienced Clinical coder. Data extraction format was used to extract information on coding accuracy and factors that could lead to errors in coding. Data analyses were done using SPSS Version 25 with focus on descriptive statistics. Results: Coders in the clinical coding unit of the hospital are Health Information Management Professionals, with no formal training in coding but, on-the-job training. Discharge summary is not completed in most discharged patients’ health records therefore, coders read through records to select diagnoses for coding. Conclusion: Absence of discharge summary could be counterproductive to clinical coding process in the hospital, resulting to time wasting, incomplete coding and coding error. Clinicians are therefore advised to write discharged summary in order to reduce coding error. Clinical Coding should be seen as an area of specialization in HIM hence, coders should be specially trained and encouraged to attend continuing professional development programme related to clinical coding. The Department of Health Records should retain experienced clinical coders and the clinical coding unit should be well-staffed to reduce work-load that could increase error in coding.
