Background
This process was initiated in early 2008 in response to the Clinical Coding Service and data quality manager's request to the medical director that there be a venue for case note review when there were queries or issues that impacted on clinical coding. It was decided that this would best be accomplished by direct engagement with the medical director.
Objective
To resolve coding queries and issues arising, particularly what information is recorded as the main condition versus the evidence in the case notes.
Outline
The Clinical Coding Service and data quality manager hold weekly meetings with the medical director. The coding which was recorded against the episode is shown to the medical director who reviews the written record in the case note for the episode. The recommendations of the medical director in light of his review inform the coding as to what was the main condition being treated or investigated.
Impact
Greater accuracy is achieved by the input of the medical director's expertise and any consistent problems with the way data is recorded can be fed into the Clinical Coding and Data Quality Group for action and resolution. This program of validation has been very successful and plans are being made to expand the amount and types of queries that will be put to other clinical leads in pursuit of excellence in coding and data recording.
Source: Tribal and Mid Staffordshire NHS Foundation Trust