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首页> 外文期刊>British journal of neurosurgery >Financial and clinical governance implications of clinical coding accuracy in neurosurgery: a multidisciplinary audit.
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Financial and clinical governance implications of clinical coding accuracy in neurosurgery: a multidisciplinary audit.

机译：金融和临床治理对神经外科临床编码准确性的影响：多学科审计。

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Clinical coding is the translation of documented clinical activities during an admission to a codified language. Healthcare Resource Groupings (HRGs) are derived from coding data and are used to calculate payment to hospitals in England, Wales and Scotland and to conduct national audit and benchmarking exercises. Coding is an error-prone process and an understanding of its accuracy within neurosurgery is critical for financial, organizational and clinical governance purposes. We undertook a multidisciplinary audit of neurosurgical clinical coding accuracy. Neurosurgeons trained in coding assessed the accuracy of 386 patient episodes. Where clinicians felt a coding error was present, the case was discussed with an experienced clinical coder. Concordance between the initial coder-only clinical coding and the final clinician-coder multidisciplinary coding was assessed. At least one coding error occurred in 71/386 patients (18.4%). There were 36 diagnosis and 93 procedure errors and in 40 cases, the initial HRG changed (10.4%). Financially, this translated to pound111 revenue-loss per patient episode and projected to pound171,452 of annual loss to the department. 85% of all coding errors were due to accumulation of coding changes that occurred only once in the whole data set. Neurosurgical clinical coding is error-prone. This is financially disadvantageous and with the coding data being the source of comparisons within and between departments, coding inaccuracies paint a distorted picture of departmental activity and subspecialism in audit and benchmarking. Clinical engagement improves accuracy and is encouraged within a clinical governance framework.
机译：临床编码是在录入编纂语言期间记录的临床活动的翻译。医疗保健资源分组（HRG）来自编码数据，用于计算向英格兰，威尔士和苏格兰的医院支付的费用，并进行国家审核和基准测试。编码是一个容易出错的过程，对神经外科手术的准确性的理解对于财务，组织和临床管理目的至关重要。我们对神经外科临床编码的准确性进行了多学科的审核。经过编码培训的神经外科医生评估了386例患者发作的准确性。当临床医生认为存在编码错误时，将与经验丰富的临床编码员进行讨论。评估了仅初始编码者的临床编码与最终临床医师编码的多学科编码之间的一致性。 71/386位患者中至少发生了一个编码错误（18.4％）。有36例诊断和93例操作错误，在40例中，初始HRG改变了（10.4％）。从财务上讲，这转化为每位患者发作111英镑的收入损失，并预计将给部门造成每年171,452英镑的损失。所有编码错误的85％是由于在整个数据集中仅发生一次编码更改而导致的。神经外科临床编码容易出错。这在财务上是不利的，并且编码数据是部门内部和部门之间进行比较的来源，编码不准确描绘了部门活动和审计和基准测试中的专科知识的失真情况。临床参与可提高准确性，并在临床管理框架内予以鼓励。

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