The Quality of Coding Medical Records of Cancer Patients Based on ICD-10 in Hospitals of Hormozgan University of Medical Sciences
Introduction: The aim of this study was to determine the status of ICD-10 codes assigned to cancer patients' medical records in terms of three attributes of accuracy, completeness, and timeliness. Method: in this cross-sectional descriptive study, 374 medical files with C00-D48 diagnosis codes...
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| Format: | Article |
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Kerman University of Medical Sciences
2019-12-01
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| Series: | مجله انفورماتیک سلامت و زیست پزشکی |
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| Online Access: | http://jhbmi.ir/article-1-379-en.html |
| _version_ | 1811176358007537664 |
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| author | Maedeh Hashemipour Farid Khorrami Mehri Ansari Tayebeh Baniasadi Nasrin Davari Mehraban Shahi |
| author_facet | Maedeh Hashemipour Farid Khorrami Mehri Ansari Tayebeh Baniasadi Nasrin Davari Mehraban Shahi |
| author_sort | Maedeh Hashemipour |
| collection | DOAJ |
| description | Introduction: The aim of this study was to determine the status of ICD-10 codes assigned to cancer patients' medical records in terms of three attributes of accuracy, completeness, and timeliness.
Method: in this cross-sectional descriptive study, 374 medical files with C00-D48 diagnosis codes were selected through stratified sampling. Data gathering tool was a researcher-made checklist consisted of clinical information summary, codes assigned by assistant professors and coders, the review and comparison of the codes, the results obtained from the control of codes by ICD-10 and the errors extracted from coders’ codes. The factors affecting the occurrence of coding errors at different levels and their impact on the accuracy and completeness of the codes were classified.
Results: Totally, coding errors were observed in 79 cases (21.74%). differences in codes at the level of the chapter were due to not following the rules for choosing the main diagnosis (30 cases) and inadequate study of the records (38 cases). In terms of completeness, in 27 cases (7.43%), codes assigned by coders were defective compared to assistant professors’ codes. In relation to the timeliness, in accordance with the WHO standard, coding was done within 48 hours of the patient's discharge.
Conclusion: According to the results, coding quality is not only dependent on the coders, but also on other factors such as documentation defect. Therefore, continuous training for both coders and documenters is necessary to resolve defects, especially in the field of cancer. It is also recommended to use the results of this study for planning related workshops. |
| first_indexed | 2024-04-10T19:50:06Z |
| format | Article |
| id | doaj.art-edd90ce7d5c7489081924c59daa9017b |
| institution | Directory Open Access Journal |
| issn | 2423-3870 2423-3498 |
| language | fas |
| last_indexed | 2024-04-10T19:50:06Z |
| publishDate | 2019-12-01 |
| publisher | Kerman University of Medical Sciences |
| record_format | Article |
| series | مجله انفورماتیک سلامت و زیست پزشکی |
| spelling | doaj.art-edd90ce7d5c7489081924c59daa9017b2023-01-28T10:31:06ZfasKerman University of Medical Sciencesمجله انفورماتیک سلامت و زیست پزشکی2423-38702423-34982019-12-0163231242The Quality of Coding Medical Records of Cancer Patients Based on ICD-10 in Hospitals of Hormozgan University of Medical SciencesMaedeh Hashemipour0Farid Khorrami1Mehri Ansari2Tayebeh Baniasadi3Nasrin Davari4Mehraban Shahi5 B.S.c Medical Records, Khatam Alanbia Hospital, Hormozgan University of Medical Sciences, Jask, Bandar Abbas, Iran Ph.D. in Health Information Management, Assistant Professor in Health Information Management, Health Information Technology Dept., Faculty of Para Medicine, Hormozgan University of Medical Sciences, Bandarabbas, Iran M.S.c of Health Information Technology, Clinical Research Development Center of Children Hospital, Hormozgan University of Medical Sciences, Bandar Abbas, Iran Ph.D. Student in Medical Informatics, Health Information Management Dept., School of ParaMedical, Tehran University of Medical Sciences, Tehran, Iran Ph.D. in Health Information Management, Associated Professor, Health Information Technology Dept., Faculty of Para Medicine, Hormozgan University of Medical Sciences, Bandarabbas, Iran Ph.D. in Health Information Management, Assistant Professor in Health Information Management, Health Information Technology Dept., Faculty of Para Medicine, Hormozgan University of Medical Sciences, Bandarabbas, Iran Introduction: The aim of this study was to determine the status of ICD-10 codes assigned to cancer patients' medical records in terms of three attributes of accuracy, completeness, and timeliness. Method: in this cross-sectional descriptive study, 374 medical files with C00-D48 diagnosis codes were selected through stratified sampling. Data gathering tool was a researcher-made checklist consisted of clinical information summary, codes assigned by assistant professors and coders, the review and comparison of the codes, the results obtained from the control of codes by ICD-10 and the errors extracted from coders’ codes. The factors affecting the occurrence of coding errors at different levels and their impact on the accuracy and completeness of the codes were classified. Results: Totally, coding errors were observed in 79 cases (21.74%). differences in codes at the level of the chapter were due to not following the rules for choosing the main diagnosis (30 cases) and inadequate study of the records (38 cases). In terms of completeness, in 27 cases (7.43%), codes assigned by coders were defective compared to assistant professors’ codes. In relation to the timeliness, in accordance with the WHO standard, coding was done within 48 hours of the patient's discharge. Conclusion: According to the results, coding quality is not only dependent on the coders, but also on other factors such as documentation defect. Therefore, continuous training for both coders and documenters is necessary to resolve defects, especially in the field of cancer. It is also recommended to use the results of this study for planning related workshops.http://jhbmi.ir/article-1-379-en.htmlcodingclassificationcancercancer registryquality |
| spellingShingle | Maedeh Hashemipour Farid Khorrami Mehri Ansari Tayebeh Baniasadi Nasrin Davari Mehraban Shahi The Quality of Coding Medical Records of Cancer Patients Based on ICD-10 in Hospitals of Hormozgan University of Medical Sciences مجله انفورماتیک سلامت و زیست پزشکی coding classification cancer cancer registry quality |
| title | The Quality of Coding Medical Records of Cancer Patients Based on ICD-10 in Hospitals of Hormozgan University of Medical Sciences |
| title_full | The Quality of Coding Medical Records of Cancer Patients Based on ICD-10 in Hospitals of Hormozgan University of Medical Sciences |
| title_fullStr | The Quality of Coding Medical Records of Cancer Patients Based on ICD-10 in Hospitals of Hormozgan University of Medical Sciences |
| title_full_unstemmed | The Quality of Coding Medical Records of Cancer Patients Based on ICD-10 in Hospitals of Hormozgan University of Medical Sciences |
| title_short | The Quality of Coding Medical Records of Cancer Patients Based on ICD-10 in Hospitals of Hormozgan University of Medical Sciences |
| title_sort | quality of coding medical records of cancer patients based on icd 10 in hospitals of hormozgan university of medical sciences |
| topic | coding classification cancer cancer registry quality |
| url | http://jhbmi.ir/article-1-379-en.html |
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