The Effects on Clinical Coding of the Critical Pathway Recording Methodology

Abstract

A two-stage study aimed to identify the effects of the critical pathway recording methodology on clinical coding practice and to determine coders' participation in pathway development. Critical pathways were found to be in widespread use, with low coder participation in pathway development and poor education on pathway data extraction. Coders favoured the traditional medical record format; private sector coders predominated amongst those who preferred to code from records containing pathways because of poor private sector clinical documentation. The documentation factors that most affected the clinical coding process were consistent with those identified previously and were primarily doctor-related.