The quality of medical record documentation and External cause of fall injury coding in a tertiary teaching hospital.

The quality of medical record documentation and External cause of fall injury coding in a tertiary teaching hospital. HIM J. 2014;43(1):6-15 Authors: Cunningham J, Williamson DW, Robinson KM, Carroll R, Buchanan R, Paul L Abstract This paper reviews the documentation and coding of External causes of admitted fall cases in a major hospital. Intensive analysis of a random selection of 100 medical records included blind re-coding in the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian Modification (ICD-10-AM), Fifth Edition for External causes to ascertain whether: (i) the medical records contained sufficient information for assignment of specific External cause codes; and (ii) the most appropriate External cause codes were assigned per available documentation. Comparison of the hospital data with the state-wide Victorian Admitted Episodes Database (VAED) data on frequency of use of External cause codes revealed that the index hospital, a major trauma centre, treated comparatively more falls involving steps, stairs and ladders. The hospital sample reflected lower usage, than state-wide, of unspecified External cause codes and Other specified activity codes; otherwise, there was similarity in External cause coding. A comparison of researcher and hospital codes for the falls study sample revealed differences. The ambulance report was identified as the best source of External caus...
Source: Health Information Management Journal - Category: Health Management Tags: HIM J Source Type: research