G310(P) Audit of discharge letter diagnosis and its effect on clinical coding

Abstract

Introduction Discharge diagnoses can have significant implications on patient management from a clinical governance point of view. It can further impact the clinical coding with a risk of potential financial loss to the service provider. Accurate clinical coding also contributes to appropriate data collection and analysis in audit and research. Aims To look at the accuracy of discharge letter primary diagnosis and co-morbidities To look at the relation between clinical coding and potential financial loss Methods We did a retrospective review of 50 discharge letters randomly selected from the paediatric wards in August 2014. An excel spread sheet was used to collect the data which included: date of admission and discharge, discharge diagnosis and any co-morbidity. The accuracy of the diagnosis was ascertained by looking through the patient notes and cross-checking them with clinical coders and against the ICD-10 manual. Results 13 out of 50 discharge letters (26%) had inaccurate diagnosis. 6 out of 50 case notes (12%) had co-morbidities that were not included on discharge letters. We looked thorough seven case notes’ discharge diagnosis (7/13) in detail and compared the financial tariff between the accurate diagnosis and the one written on the discharge letter. We estimated an income loss of £1,359 . Discussion Coding accuracy on average is high in the United Kingdom, especially for operations and procedures.1 Inaccurate coding can have significant financial implications.2 There is a need to raise the awareness of the importance of accurate clinical coding for all clinicians. Conclusion 1. Our audit demonstrated that inaccurate diagnosis can have significant financial implications 2. A Do’s and Don’ts table was designed and circulated to all the clinical staff (see [Figure 1][1]) 3. We aim to raise the awareness of clinical coding during junior doctors induction and aim to re-audit in 6 months’ time. ![Abstract G310(P) Figure 1][2] Abstract G310(P) Figure 1 References 1. Campbell SE, Campbell MK, Grimshaw JM, Walker AE. A systematic review of discharge coding accuracy. J Public Health Med. 2001; 23(3):205–11 2. Stevens S, Unwin CE, Codde JP. A review of hospital medical record audits: implications for funding and training. Aust Health Rev. 1998; 21(3):78–91 [1]: #F1 [2]: pending:yes