Physician involvement enhances coding accuracy to ensure national standards: An initiative to improve awareness among new junior trainees

Abstract

Record Keeping Standards is a development led by the Royal College of Physicians of London (RCP) Health Informatics Unit and funded by the National Health Service (NHS) Connecting for Health. A supplementary report produced by the RCP makes a number of recommendations based on a study held at an acute hospital trust. We audited the medical notes and coding to assess the accuracy, documentation by the junior doctors and also to correlate our findings with the RCP audit. Northern Lincolnshire & Goole Hospitals NHS Foundation Trust has 114,000 'finished consultant episodes' per year. A total of 100 consecutive medical (50) and rheumatology (50) discharges from Diana Princess of Wales Hospital from August-October 2009 were reviewed. The results showed an improvement in coding accuracy (10% errors), comparable to the RCP audit but with 5% documentation errors. Physician involvement needs enhancing to improve the effectiveness and to ensure clinical safety. © 2011 Royal College of Physicians of Edinburgh.