Good practice from 2008/09 audits
Background
The Trust started the process in early 2008. The Clinical Coding Service and Data Quality Manager’s asked the Medical Director to create a place for case note review when there were queries or issues that affect clinical coding. The Trust decided the best way to do this would be through direct engagement with the Medical Director.
Objective
To resolve coding queries and issues, particularly what information clinicians 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. They show the coding which has been recorded against the episode to the Medical Director. He then reviews the written record in the case note for the episode. The Medical Director’s recommendations, which he has based on his review, set out in the coding what was the main condition the clinician was treating or investing.
Impact
Using the Medical Director’s expertise means the coding is more accurate and any consistent problems with the way clinicians are recording data can be fed into the Clinical Coding and Data Quality Group for action and resolution. This approval programme has been very successful. The Trust is planning to expand the number 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