Improving the quality of clinical coding: a comprehensive audit model
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 lea...
| Published in: | Journal of Health Management & Informatics |
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| Main Authors: | , , |
| Format: | Article |
| Language: | English |
| Published: |
Shiraz University of Medical Sciences
2014-04-01
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| Subjects: | |
| Online Access: | http://jhmi.sums.ac.ir/index.php/JHMI/article/view/16/11 |
| Summary: | 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. |
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| ISSN: | 2322-1097 2423-5857 |