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Driving Clinical Coding Forward Data Quality for Improvement – the clinical coder’s perspective Jayne Harding Senior Clinical Classifications Advisor 24 November 2009 Clinical classifications: • The NHS Classification Service is the definitive source for clinical coding guidance and sets the national classifications standards in use in the NHS • Work collaboratively with NICE, Audit Commission, WHO and set the NHS Fundamental Information Standards What is Clinical Coding? Clinical coding is 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. How? Using Classifications to code ‘A classification is a systematic arrangement of like entities based on differing characteristics’ • Groups ‘like’ entities together in a standardised medical language • Provides a structured framework for statistical information • Governed by rules and conventions • Nationally and internationally recognised Accuracy is reliant upon… • The Clinician providing all the information on the patient’s diagnoses and treatment dated and timed, with signature. • The Clinical Coder translating that information into the appropriate coded format to reflect the patient’s hospital stay. What do coders use to code? • The information for coding comes from the ‘source document’ • The source document for coding varies from hospital to hospital but is usually the patient’s casenotes • This document includes: • discharge summaries / proformas • clinical work sheets • hospital to patient and hospital to GP documentation Clinicians and Data Quality The source documentation must: • Be clear and detailed - writing clearly in indelible ink • Provide accurate and complete information • Clearly record all diagnoses including comorbidities and procedures, writing the main diagnosis first • Avoid abbreviations eg ‘M.S.’ could mean multiple sclerosis or mitral stenosis Clinicians and Data Quality: • Sign and date every entry, print name and position • Ensure patient’s name is on every page • Let the admin staff know when you are removing notes • Every detail of the patient’s episode of care is important, including transfers What your coders cannot do: Guess: Any ‘query’ diagnoses, or diagnoses preceded by a ‘?’ cannot be coded by clinical coding staff Wait: Coders must meet strict time deadlines to meet DH and audit requirements Work alone: They need clinical staff to collaborate Support Coder • Understand their role • Start with junior doctor staff – train them early to collaborate with their coder effectively • http://www.connectingforhealth.nhs.uk/clinicalc oding/noncoders/clinicians • Support investment in coder’s training and development • Adopt the basic principles to ensure accurate coding Ongoing - OPCS-4: • Harmonise more effectively with the clinical recording terminologies to maintain operability • Co-morbidities guidance refined and will be clinically driven • High level backing from DH to progress The future - OPCS-4 e-book • Will reproduce the Tabular and Index • Hold national clinical coding standards including Coding Clinics • Comprehensive, search, navigation, retrieval • Receive updates automatically • Will support individual notes, annotations • Provide email functionality Useful Contacts Helpdesk and all queries: [email protected] Website including resources for clinicians: www.cfh.nhs.uk/clinicalcoding/noncoders OPCS portal: www.cfh.nhs.uk/opcsrequestsportal Trud for releases: https://www.uktcregistration.nss.cfh.nhs.uk.