Clinical coding - an insight into healthcare data

Abstract

Clinical coding is an important function within healthcare informatics. Coding datasets have various statistical and clinical uses: a high level of accuracy, completeness and specificity is paramount. Preventable errors can accumulate along the coding pathway and may have significant implications for health care management worldwide. Relevance Amongst other functions, clinical coding datasets are used for policy creation, clinical audit and finance. Both clinical staff and coding professionals play an equally important role in ensuring accurate reporting of hospital activity, but the nature and importance of the clinician’s role is often misunderstood and underappreciated. The coding pathway is highly susceptible to human error with clinician-based errors ranging from incorrectly defining a clinical entity to underreporting comorbidities. Clinical staff should be aware of the importance of clinical coding, its uses and the role they play in ensuring accuracy: a hospital is measured by its output data. High-quality data leads to well-informed service provision, resource allocation and business planning which cumulates into enhanced patient outcomes. Take Home Messages Errors occurring along the coding pathway can have significant financial and statistical ramifications. Clinicians and coding professionals must work collaboratively to improve the quality of healthcare data flows. Regular engagement between all influential parties along the coding pathway is vital, with frequent reviews of clinical documentation and coding reports a firm foundation for continual improvement. Accurate and reliable healthcare data supports the optimisation of patient care.