the relationship between health record documentation and clinical coding

HIMAA Conference 16/10/09www.ifhro.orgwww.ifhro.org

The Relationship between Health The Relationship between Health Record Documentation and Clinical Record Documentation and Clinical

CodingCoding

Lorraine Nicholson

President of IFHRO (International Federation of Health Records Organisations) & Independent Health Records Consultant

Co-Author: Sue WalkerDirector, National Centre for Health Information Research and Training,

Australia

HIMAA Conference, Perth, Australia16th October 2009


The Relationship between Health Record The Relationship between Health Record Documentation and Clinical CodingDocumentation and Clinical Coding

Clinical coding is the translation of medical terminology as written by the clinician into a coded format which is nationally and internationally recognised

i.e. It is the translation into code of what has been documented by treating clinical staff

Coders should not make assumptions but should only code what is documented

The accuracy of clinical coding is dependent on the clinician recording clear and complete diagnostic and procedural information

Coding reflects the quality of the source documentation as well as the skills and

knowledge of the coder.


Primary Purposes of Health Primary Purposes of Health Records (1)Records (1)

Health Records are basic clinical tools Accurate, complete and timely documentation

in the record is the responsibility of clinician treating the patient

The primary purpose of the Health Record is to facilitate clinical care

The record acts as an ‘aide-memoire’ for the treating clinician & is an essential communication tool for other healthcare professionals

It facilitates the patient receiving appropriate treatment at the right time


Primary Purposes of Health Primary Purposes of Health Records (2)Records (2)

Records provide a permanent account of diagnostic & treatment decisions & a means by which a clinician’s treatment can be judged

The record provides evidence of what was done, when & why

It also provides the means to answer questions about diagnosis & treatment & defend medico-legal claims where necessary


Secondary Purposes of Health Secondary Purposes of Health RecordsRecords

To provide a dependable source of clinical data to support clinical audit, research, teaching, resource allocation and performance planning

Clinical coding is the link between the primary and secondary purposes of the record


Existing Standards for Health Records Existing Standards for Health Records

There are two types of existing standards for Health Records

1. Structure of the Health Record

2. Content and completeness of the documentation within the record


Structure of the Health RecordStructure of the Health Record

Standards for organisation & configuration of Health Records are needed so that records are structured appropriately

Records are a chronological record of important events & need to be ordered appropriately so that relevant clinical information is recorded in the right place to enable clinicians to locate it quickly & easily when required


Content and Completeness of Content and Completeness of

Documentation within the recordDocumentation within the record Content and completeness standards apply to the

format & definition of what is recorded in the agreed structure to ensure that:

Entries are legible Authors of entries are attributable Entries are dated, signed and timed Amendments are made transparently Entries are made contemporaneously whenever possible but

as soon as possible after the event/encounter There is limited use of abbreviations and jargon Personal or subjective statements are not recorded There is no documentation of value judgements and

speculation irrelevant documents are not included


Importance of Standards for Importance of Standards for Health RecordsHealth Records

Both types of standards for records are vitally important for clinical coding purposes

1. STRUCTURE - so that relevant information to determine complete & accurate codes can be easily located

2. CONTENT - because the completeness and accuracy of the coding relies on content


NHS Standards (England)NHS Standards (England) The Health Informatics Unit at the Royal College of

Physicians (RCP) in London has coordinated the development and piloting of nationally agreed standards for the structure and content of Health Records that have been agreed for all hospital specialties

The project was funded by NHS Connecting for Health and the standards were ‘signed off’ in April 2008 by the Academy of Medical Royal Colleges

The standards were passed as fit for purpose Psychiatry and Paediatrics - although the information

that they require is different from and additional to that covered by the standardised headings, the requirements for these specialties can be accommodated within the proposed standards structure


EHR in the United KingdomEHR in the United Kingdom England has a population of 60 million & is the largest

of the four “home countries” of the UK (England, Scotland, Wales & Northern Ireland)

The National Health Service (NHS) in England had an overall budget for 2007/08 of £96billion

It is the largest employer in Europe & one of the largest in the world employing 1.3 million people

There are 600 NHS healthcare provider organisations Over 35,000 different categories of treatment Each home country has its own approach to the

development & implementation of Electronic Health Records but this presentation focuses on EHR development in England


National EHR Development in National EHR Development in EnglandEngland

National EHR development in England is the responsibility of NPfIT (£6.2 billion)

The NHS Care Records Service will provide 60 million NHS patients with an individual electronic NHS Care Record providing details of key treatments and care within the health service and/or the social care sector

There are two principal components to the electronic patient record programme for hospitals in England

1. The Summary Care Record (held nationally) 2. The Detailed Care Record (held locally).


On-Going Use of the StandardsOn-Going Use of the Standards The standards developed by the RCP have been

submitted to NHS Connecting for Health which is responsible for the development of the national Electronic Health Record in England

Work on definitions that will meet the rigorous requirements for IT implementation is currently underway

The definitions will then be submitted to the NHS Information Standards Board for Health & Social Care for approval

All IT system suppliers to the NHS will be required to use the standards for their EPR solutions

Many hospitals & IT suppliers are already implementing them in both paper & electronic format


Supporting the Use of the RCP Supporting the Use of the RCP Standards OperationallyStandards Operationally

The NHS Digital & Health Information Policy Directorate in England has published a two part clinician’s guide to the standards:

Part 1 - Rationale for developing and introducing the national professional record keeping standards &s the expected benefits

Part 2 - Generic Health Record Keeping Standards & the structure & content standards for admission, handover & discharge documents


Importance of Standards for Electronic Importance of Standards for Electronic Health Record DevelopmentHealth Record Development

The implementation of EHR’s in the NHS significantly increases the importance of structured records & this applies to all EHR systems wherever they are implemented around the world

With the development of EHR’s there is an urgent need to standardise the structure & content of clinical information recorded & communicated through the Health Record


Standards to EnsureStandards to Ensure Safer & More Safer & More Efficient & Effective CareEfficient & Effective Care

Structure & content standards are crucial to ensure that clinical information can be consistently stored, retrieved & shared between information systems

The standards must therefore be based on professional agreement that reflects best clinical practice

Standards must be incorporated into information systems by skilled IT professionals

Patients must also be involved at all stages of standards development


The Main Benefit of Structure & The Main Benefit of Structure & Content Standards in EHR Content Standards in EHR

SystemsSystems

Clinical information in electronic health records will be recorded once, and made available when and where required, thus improving efficiency and saving time


Benefits of Standards for HIM’s & Benefits of Standards for HIM’s & CodersCoders

Improves HIM’s & Coders ability to abstract comprehensive and relevant clinical information on which to assign the most complete and accurate set of codes to describe the clinical encounter


Standards & Coding QualityStandards & Coding Quality

ICD-10 contains recommended format for medical certificate of cause of death but many of the mortality coding rules have been developed to address issues caused by inadequate documentation of cases

Instructions for morbidity coding have been developed to manage poor documentation

Having standards for record structure and content would go some way to addressing poor documentation before it becomes a coding problem


Improving Coding Quality GloballyImproving Coding Quality Globally

Availability of standards for Health Records (& potentially other source documents, such as death certificates) for use internationally would assist with the provision of high quality coded data

Most countries with well-developed health information systems already have their own standards

Small and developing countries in which there are few trained Health Record professionals may not have access to such standards


Improving Coding Quality GloballyImproving Coding Quality Globally

The authors of this paper suggest that a discussion about the development of simple, but comprehensive, standards for source documents be considered as another means to improving coding quality around the world


Thank YouThank You

Lorraine Nicholson

President of IFHRO

[email protected]

+44 01706 355957

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