Background
This pilot scheme was introduced in November 2008. A qualified clinical coding officer attends the daily ward rounds for emergency general surgery patients.
Objective
To improve the patient record information and quality of general surgery coding and also improve working relationships between clinical coders and clinicians.
Outline
During the ward round, which a clinical coder attends, the electronic discharge summaries of patients who are ready to be discharged are initiated at the patient's bed. The coding office is on hand to offer advice and guidance as to the depth and type of information required in order for the episode to be coded correctly.
Impact
A recent process review on one of the surgical wards involved in the pilot highlighted that the completeness and consistency of information included on the discharge summaries has improved since the introduction of the pilot. The profile of clinical coding has also been significantly improved within the surgical directorate and has facilitated closer working relationships between clinicians and clinical coders which have resulted in improvements in the quality of clinical coding.
Source: Tribal and North Tees and Hartlepool NHS Foundation Trust