Area of good practice
Theatre coding
Background
One of the recommendations from the 2008/09 PbR audit was to review how information is provided to coders to ensure accuracy and timeliness. Following this, a review took place. The Trust decided that to ensure timeliness and to get the greatest accuracy, coders would record the relevant episodes in real time in theatre while the relevant clinician is available if there is a query.
Objective
To ensure coders record all relevant procedural information in an accurate and timely manner.
Outline
Experienced clinical coders who have been coding for a minimum of five years will complete procedural coding in the theatres. The theatre coders are paid at band 5 and rotated to aid their personal development.
Impact
Intended impact
Intended impact The impact is to achieve high-quality clinical coded data which is both consistently accurate and recorded in a timely manner.
Actual impact
The actual impact is as intended. Coders can discuss and resolve any queries or complex cases with the relevant clinician. The procedural coding is always up to date as coders complete it almost in real time in the theatre.