Clinical coding is the process of transforming the information about diseases or procedures recorded in the health records into numeric or alphanumeric codes, in order to categorise health record information.
It allows for reliable collation, aggregation and comparison of healthcare data on local and national platforms. As well as being useful for auditing purposes, it is used for tracking patients outcomes and measuring treatment effectiveness.
And increasingly clinical coders are using our Dorset Care Record to help them, particularly across Dorset’s acute hospitals.
Chris Webb, who has been working this year as a clinical coder at Dorset County Hospital, said he has found the health and care record useful because of its plethora of information.
“As a clinical coder, I used the Dorset Care Record as the best and most complete record of patients’ co-morbidities, which is key to producing accurate and complete patient coding.
“Prior to having access to the DCR, as coders we would get our information from the hard copy patient notes, patient letters on the Patient Admin System (PAS) or historical Electronic Discharge Summaries.
“The DCR is seen as the easiest and most complete source to get the information required,” he added.
Dorset County Hospital started giving its clinical coding team access to the DCR in the summer and within a couple of months two of the coders were in their top 10 of users. Over the past few months the whole team has been given access and they’ve also been set up on the benefits register.
Ends
I would like to know if the trusts in Dorset have considered the impact this will have on their data and how this will compare with other trusts following the national guidelines for clinical coding. This will probably make them as outliers for the data when compared nationally to trusts not doing the same thing. The data on this system is also often collected by gp surgeries and the co-mobidites maybe out of date or not relevant to certain episodes which will depend on the skill level and experience of the coder to determine. I would think this should only be used cautiously and to plug gaps in missing information. Definitely not used on every possible FCE.
Thanks Bobby – I’ll be in touch with DCH’s Digital team with your thoughts and get back to you in early January. Wishing you a very happy New Year, from the DCR team