مجله انفورماتیک سلامت و زیست پزشکی (Dec 2019)
The Quality of Coding Medical Records of Cancer Patients Based on ICD-10 in Hospitals of Hormozgan University of Medical Sciences
Abstract
Introduction: The aim of this study was to determine the status of ICD-10 codes assigned to cancer patients' medical records in terms of three attributes of accuracy, completeness, and timeliness. Method: in this cross-sectional descriptive study, 374 medical files with C00-D48 diagnosis codes were selected through stratified sampling. Data gathering tool was a researcher-made checklist consisted of clinical information summary, codes assigned by assistant professors and coders, the review and comparison of the codes, the results obtained from the control of codes by ICD-10 and the errors extracted from coders’ codes. The factors affecting the occurrence of coding errors at different levels and their impact on the accuracy and completeness of the codes were classified. Results: Totally, coding errors were observed in 79 cases (21.74%). differences in codes at the level of the chapter were due to not following the rules for choosing the main diagnosis (30 cases) and inadequate study of the records (38 cases). In terms of completeness, in 27 cases (7.43%), codes assigned by coders were defective compared to assistant professors’ codes. In relation to the timeliness, in accordance with the WHO standard, coding was done within 48 hours of the patient's discharge. Conclusion: According to the results, coding quality is not only dependent on the coders, but also on other factors such as documentation defect. Therefore, continuous training for both coders and documenters is necessary to resolve defects, especially in the field of cancer. It is also recommended to use the results of this study for planning related workshops.
