Improving the quality of clinical coding: a comprehensive audit model

Introduction: The review of medical records with the aim of assessing the quality of codes has long been conducted in different countries. Auditing medical coding, as an instructive approach, could help to review the quality of codes objectively using defined attributes, and this in turn would lea...

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Main Authors: Hamid Moghaddasi, Reza Rabiei, Nasrin Sadeghi
Format: Article
Language:English
Published: Shiraz University of Medical Sciences 2014-04-01
Series:Journal of Health Management & Informatics
Subjects:
Online Access:http://jhmi.sums.ac.ir/index.php/JHMI/article/view/16/11
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author Hamid Moghaddasi
Reza Rabiei
Nasrin Sadeghi
author_facet Hamid Moghaddasi
Reza Rabiei
Nasrin Sadeghi
author_sort Hamid Moghaddasi
collection DOAJ
description Introduction: The review of medical records with the aim of assessing the quality of codes has long been conducted in different countries. Auditing medical coding, as an instructive approach, could help to review the quality of codes objectively using defined attributes, and this in turn would lead to improvement of the quality of codes. Method: The current study aimed to present a model for auditing the quality of clinical codes. The audit model was formed after reviewing other audit models, considering their strengths and weaknesses. A clear definition was presented for each quality attribute and more detailed criteria were then set for assessing the quality of codes. Results: The audit tool (based on the quality attributes included legibility, relevancy, completeness, accuracy, definition and timeliness); led to development of an audit model for assessing the quality of medical coding. Delphi technique was then used to reassure the validity of the model. Conclusion: The inclusive audit model designed could provide a reliable and valid basis for assessing the quality of codes considering more quality attributes and their clear definition. The inter-observer check suggested in the method of auditing is of particular importance to reassure the reliability of coding.
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spelling doaj.art-ec6c2d73737448e8a643bd7138cd8d9d2022-12-22T01:22:29ZengShiraz University of Medical SciencesJournal of Health Management & Informatics2322-10972423-58572014-04-01123640Improving the quality of clinical coding: a comprehensive audit modelHamid Moghaddasi0Reza Rabiei1Nasrin Sadeghi2Department of Health Information Management and Medical Informatics; School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IranDepartment of Health Information Management and Medical Informatics; School of Paramedical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IranTabriz University of Medical Sciences, Tabriz, IranIntroduction: The review of medical records with the aim of assessing the quality of codes has long been conducted in different countries. Auditing medical coding, as an instructive approach, could help to review the quality of codes objectively using defined attributes, and this in turn would lead to improvement of the quality of codes. Method: The current study aimed to present a model for auditing the quality of clinical codes. The audit model was formed after reviewing other audit models, considering their strengths and weaknesses. A clear definition was presented for each quality attribute and more detailed criteria were then set for assessing the quality of codes. Results: The audit tool (based on the quality attributes included legibility, relevancy, completeness, accuracy, definition and timeliness); led to development of an audit model for assessing the quality of medical coding. Delphi technique was then used to reassure the validity of the model. Conclusion: The inclusive audit model designed could provide a reliable and valid basis for assessing the quality of codes considering more quality attributes and their clear definition. The inter-observer check suggested in the method of auditing is of particular importance to reassure the reliability of coding.http://jhmi.sums.ac.ir/index.php/JHMI/article/view/16/11QualityClinical codesAudit modelAudit toolData quality attributes
spellingShingle Hamid Moghaddasi
Reza Rabiei
Nasrin Sadeghi
Improving the quality of clinical coding: a comprehensive audit model
Journal of Health Management & Informatics
Quality
Clinical codes
Audit model
Audit tool
Data quality attributes
title Improving the quality of clinical coding: a comprehensive audit model
title_full Improving the quality of clinical coding: a comprehensive audit model
title_fullStr Improving the quality of clinical coding: a comprehensive audit model
title_full_unstemmed Improving the quality of clinical coding: a comprehensive audit model
title_short Improving the quality of clinical coding: a comprehensive audit model
title_sort improving the quality of clinical coding a comprehensive audit model
topic Quality
Clinical codes
Audit model
Audit tool
Data quality attributes
url http://jhmi.sums.ac.ir/index.php/JHMI/article/view/16/11
work_keys_str_mv AT hamidmoghaddasi improvingthequalityofclinicalcodingacomprehensiveauditmodel
AT rezarabiei improvingthequalityofclinicalcodingacomprehensiveauditmodel
AT nasrinsadeghi improvingthequalityofclinicalcodingacomprehensiveauditmodel