Background
All coded activity is sent for validation on a weekly basis to consultants in a number of specialties.
Objective
To improve coding and case note quality especially in complex cases where clarity in the case notes is key.
Outline
Coded activity (ICD10 and OPCS4 codes) is sent out by email in a spreadsheet to consultants in Trauma and Orthopaedic, Oral Surgery, Neurosurgery, Cardiology, General Surgery, Pain and Elderly Medicine. Consultants validate the spreadsheet and return them to the coding department with comments if they believe changes are required. Comments received from clinicians concerning complex cases, particularly in Neurosurgery and Trauma specialties, are followed up with reference to case notes. Coders regularly discuss issues with clinicians to ensure that episodes are accurately coded.
Impact
Involving clinicians in validating codes helps them to understand how important their role is providing good quality information to clinical coders. The 2008/09 audit looked at Trauma and Orthopaedics and found the case notes to be of a high standard.
Source: 3M and North Bristol NHS Trust