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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Format: | Article |
Language: | English |
Published: |
Shiraz University of Medical Sciences
2014-04-01
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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. |
first_indexed | 2024-12-11T03:27:05Z |
format | Article |
id | doaj.art-ec6c2d73737448e8a643bd7138cd8d9d |
institution | Directory Open Access Journal |
issn | 2322-1097 2423-5857 |
language | English |
last_indexed | 2024-12-11T03:27:05Z |
publishDate | 2014-04-01 |
publisher | Shiraz University of Medical Sciences |
record_format | Article |
series | Journal of Health Management & Informatics |
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 |