Clinical Coding - The Clinicians Role

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Clinical Coding – The Clinicians’ role
This presentation has been produced by the NHS Classifications Service at NHS
Connecting for Health.
It is intended that this presentation form the bases for the key messages that need to be
given to the junior members of consultants’ teams in their induction day to ensure
that they are aware of the need for accurate clinically coded data. This presentation
is designed to last for approximately 7-10 minutes
Tutors notes and guidance have been supplied with this presentation.
Comments would be welcomed for future revisions.
NHS Classifications Service
NHS Connecting for Health
2nd Floor Princes Exchange
Princes Square,
Leeds,
LS1 4HY
Version 1.0
Clinical Coding
The Clinicians’ Role
Clinical Coding Department
What is Clinical Coding?
‘… the translation of medical terminology,
as written by the clinician, to describe a
patient’s complaint, problem, diagnosis,
treatment or reason for seeking medical
attention, into a coded format’ which is
nationally and internationally
recognised.
(NHS Information Authority, Clinical Coding Instruction Manual)
Main Classifications
ICD-10
• International
• Used to capture diagnostic clinical
data
OPCS-4
• UK specific
• Used to capture surgical interventions
& procedures
Weekly Bills of Mortality
LONDON week ending 31st January 1634
The Diseases and Casualties this week
Abortive
Aged
Bedridden
Bloody flux
Bruised
Cancer
Chilbed
Chrisoms
Consumption
Convulsions
Cough
Dropsie
2
36
1
1
1
1
3
19
77
44
2
1
Males 107
Christened Female 109
In all
216
Executed
Feaver
Flox and smallpox
Found dead in the
street (an infant)
French pox
Gripping in the
guts
13
Jaundies
Infants
Killed with a fall
Murthered
Buried
33
10
5
1
1
1
18
3
1
Males
213
Females 196
In all
409
Overlaid
Quinsie
Rickets
Rising of the lights
Scowering
Scurvey
Stillborn
Stone
Stopping of the
stomach
Suddenly
Teeth
Winde
Worms
Plague
2
1
8
8
1
2
9
1
3
6
16
3
1
0
Decreased in the buriels this week - 63
Parishes clear of the plague - 130 Parishes infected - 20
The assize of bread set forth by order of the Lord Mayor and Court of Aldermen
A penny wheaten loaf to contain eleven ounces and a half and three halfpenny white loaves the like
weight
Accuracy is reliant upon…
The Clinician providing the information on
the patient’s diagnoses and treatment
The Clinical Coder translating that
information into the appropriate coded
format to reflect the patient’s hospital
stay
Accurate and Complete
Information
Complete diagnostic and procedural
information is vital.
• Hepatitis
K75.9 Inflammatory liver disease, unspecified
• Acute Hepatitis
K72.0 Acute and subacute hepatic failure
• Alcoholic Hepatitis
K70.1 Alcoholic Hepatitis
Possible and ? Diagnoses
Chest Pain ?MI
Chest pain
investigations
confirmed MI
Abdominal pain - possibly
cholecystitis, possibly
appendicitis
Abdominal pain treated
as appendicitis
Clinicians and Data Quality
The source documentation should:
• Be accurate and complete
• Reflect the patient’s episode of care
• Avoid the use of abbreviations
• Be clear and detailed
• Recording is legible and in indelible ink
Uses of Clinical Coded Data
Treatment
effectiveness
Cost analysis
Commissioning
Clinical
Clinical audit
Statistical
Health trends
Clinical
Indicators
Florence Nightingale 1863
"I am fain to sum up with an urgent appeal
for adopting … some uniform system of
publishing the statistical records of hospitals.
There is a growing conviction that in all
hospitals, even in those which are best
conducted, there is a great and unnecessary
waste of life … In attempting to arrive at the
truth, I have applied everywhere for
information, but in scarcely an instance have
I been able to obtain hospital records fit for
any purposes of
comparison … If wisely used, these improved statistics
would tell us more of the relative value of particular
operations and modes of treatment than we have means
of ascertaining at present?"
Florence Nightingale in Notes on Hospitals, London: Longman,
Green, Roberts,Longman, and Green, 1863.
Important messages
The information that you write on the source documentation
must:
• Be complete and accurate
• Reflect the patient’s episode of care
• Avoid the use of abbreviations
• Be clear and detailed
• Recording is legible and in indelible ink
Anything that is unclear about a patient’s stay the Clinical
Coding Department will clarify with the appropriate
member of the consultant team to ensure accuracy in the
clinically coded data.
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