Background
A clinical validation scheme was implemented within General Medicine speciality at the main Hospital site at Bromley Hospitals NHS Trust.
Objective
To improve documentation and coding quality.
Outline
The senior registrar or the consultant meet with members of the coding team each week to review topical coding issues and the case notes for each episode when they require additional clinical input. As a result, doctors are more aware of the importance of documenting specific diagnosis and procedures, provide greater clarity on operation sheets and have a better understanding of the depth of information that clinical coders require.
Impact
The validation scheme has improved the quality of source documentation and improved clinicians understanding of the coding process. As a result, clinicians have greater confidence in the accuracy of the clinical coding and have more ownership of their data.
Source: Tribal and South London Healthcare NHS Trust