Coding external causes of injuries: Problems and solutions

McKenzie, Kirsten; Enraght-Moony, Emma; Harding, Leith; Walker, Susan; Waller, Garry S.; Chen, Linping

doi:10.1016/j.aap.2007.09.008

Cited by 19 publications

(10 citation statements)

References 9 publications

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“…When present, the Ambulance Report was the best source of information for mechanism of injury, place of occurrence and activity, and contained more External cause information than Emergency Department notes, Progress Notes or the Discharge Summary. Consistent with McKenzie et al's (2008) findings, the Discharge Summary was found to be the poorest source of information. The Emergency Department record and Discharge Summary form in our sample lacked prompts on collection of injury surveillance data.…”

Section: Is Medical Record Detail Sufficient For Coding?supporting

confidence: 89%

The Quality of Medical Record Documentation and External Cause of Fall Injury Coding in a Tertiary Teaching Hospital

Cunningham

Williamson

Robinson

et al. 2014

HIM J

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This paper reviews the documentation and coding of External causes of admitted fall cases in a major hospital. Intensive analysis of a random selection of 100 medical records included blind re-coding in the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian Modification (ICD-10-AM), Fifth Edition for External causes to ascertain whether: (i) the medical records contained sufficient information for assignment of specific External cause codes; and (ii) the most appropriate External cause codes were assigned per available documentation. Comparison of the hospital data with the state-wide Victorian Admitted Episodes Database (VAED) data on frequency of use of External cause codes revealed that the index hospital, a major trauma centre, treated comparatively more falls involving steps, stairs and ladders. The hospital sample reflected lower usage, than state-wide, of unspecified External cause codes and Other specified activity codes; otherwise, there was similarity in External cause coding. A comparison of researcher and hospital codes for the falls study sample revealed differences. The ambulance report was identified as the best source of External cause information; only 50% of hospital medical records contained sufficient information for specific code assignation for all three External cause codes, mechanism of injury, place of occurrence and activity at time of injury. Whilst all medical records contained mechanism of falls injury information, 16% contained insufficient details, indicating a deficiency in medical record documentation to underpin external cause coding. This was compounded by flaws in the ICD-10-AM classification.

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Section: Is Medical Record Detail Sufficient For Coding?supporting

confidence: 89%

The Quality of Medical Record Documentation and External Cause of Fall Injury Coding in a Tertiary Teaching Hospital

Cunningham

Williamson

Robinson

et al. 2014

HIM J

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“…Missing E-codes could result from insufficient injuryrelated details in patients' medical records. Previous research has found that medical records with fewer details were least likely to be E-coded and that coders believed better clinical documentation would improve E-coding rates [18,[27][28]. In this patient population, we found sufficient information in most medical records to assign at least a nonspecific E-code capturing the broad source of injury (e.g., E819.x: motor vehicle traffic accident of unspecified nature).…”

Section: Discussionmentioning

confidence: 68%

Accuracy of external cause-of-injury coding in VA polytrauma patient discharge records

Carlson¹,

Nugent²,

Grill³

et al. 2010

JRRD

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Abstract-Valid and efficient methods of identifying the etiology of treated injuries are critical for characterizing patient populations and developing prevention and rehabilitation strategies. We examined the accuracy of external cause-of-injury codes (E-codes) in Veterans Health Administration (VHA) administrative data for a population of injured patients. Chart notes and E-codes were extracted for 566 patients treated at any one of four VHA Polytrauma Rehabilitation Center sites between 2001 and 2006. Two expert coders, blinded to VHA E-codes, used chart notes to assign "gold standard" E-codes to injured patients. The accuracy of VHA E-coding was examined based on these gold standard E-codes. Only 382 of 517 (74%) injured patients were assigned E-codes in VHA records. Sensitivity of VHA E-codes varied significantly by site (range: 59%-91%, p < 0.001). Sensitivity was highest for combat-related injuries (81%) and lowest for fall-related injuries (60%). Overall specificity of E-codes was high (92%). E-coding accuracy was markedly higher when we restricted analyses to records that had been assigned VHA E-codes. E-codes may not be valid for ascertaining source-of-injury data for all injuries among VHA rehabilitation inpatients at this time. Enhanced training and policies may ensure more widespread, standardized use and accuracy of E-codes for injured veterans treated in the VHA.

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“…7 Concern regarding improvements to the quality of information on external causes of hospitalizations in Brazil is not recent, 9,11 and this fi eld of study is not limited to Brazilian researchers. 1,7,12,13 The Ministry of Health's decision to make it mandatory to insert a code for the external cause in the HIS-SUS database, for all hospitalizations due to injuries, poisoning or other consequences of accidents or violent events, is in keeping with the proposals from the Centers for Disease Control and Prevention (CDC) for improving the quality of information on these causes, in relation to hospitalizations in the United States. 1 In that country, there is great variability in the quality of the information on hospital morbidity due to external causes between the states.…”

Section: Discussionmentioning

confidence: 98%

“…The following strategies should be considered: investment in awareness-raising and capacitation of the professionals providing attendance in emergency and admission sectors of SUS hospitals or hospitals under contracts with SUS, so that they can adequately record the external cause on the attendance cards; and adoption of standardized forms for obtaining details on the external cause that gave rise to the hospitalization; and training for the people performing the coding. 1,13 Since the implementation and regulation of SUS, technicians and policy-makers in Brazilian municipalities have had responsibilities for managing the healthcare information system and for analysis and dissemination of data that did not exist not long ago. Thus, municipalities that, like the one studies here, have services for auditing, evaluating and controlling hospitalizations funded by SUS need to be concerned about analyzing the coverage and quality of the data produced by this system, so that the data may be useful for decisionmaking within this sector and may provide support for other sectors or organizations involved in facing up to healthcare problems.…”

Section: Discussionmentioning

confidence: 99%

Qualidade da informação sobre causas externas no Sistema de Informações Hospitalares

Tomimatsu¹,

Andrade²,

Soares³

et al. 2009

Rev. Saúde Pública

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OBJECTIVE:To analyze the coverage and quality of the data on hospitalizations due to external causes in the Hospital Information System of the Brazilian National Health System. METHODS:Hospitalizations recorded in the Hospital Information System of 11 hospitals in two municipalities (Londrina and Maringá, Southern Brazil), in 2004, were compared with hospitalizations identifi ed as consequences of external causes through investigating medical records, complemented with mortality and pre-hospital data. The crude agreement rate, sensitivity and positive predictive value were calculated. The profi le of groups of hospitalization causes recorded in the System was compared with that obtained from investigations. RESULTS:In Londrina, 3,002 hospitalizations due to external causes were recorded in the System and, in Maringá, 1,403. The investigations found 4,018 and 2,370, respectively. The System presented high positive predictive values for hospitalizations due to external causes in both municipalities: 97.7% in Londrina and 98.6% in Maringá. However, the sensitivity was low: 57.3% in Maringá and 73% in Londrina, thus denoting underrecording of these causes. Comparison between the profi les of the types of causes revealed that there was underestimation of some causes in the System, especially regarding accidents due to exposure to inanimate mechanical forces, assaults and intentional self-harm. CONCLUSIONS:Underrecording of hospitalizations due to external causes and some distortions regarding the types of causes occurred in the Hospital Information System in both municipalities. Detection of these defi ciencies may contribute towards the process of improving the quality of the information in this System.

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Coding external causes of injuries: Problems and solutions

Cited by 19 publications

References 9 publications

The Quality of Medical Record Documentation and External Cause of Fall Injury Coding in a Tertiary Teaching Hospital

The Quality of Medical Record Documentation and External Cause of Fall Injury Coding in a Tertiary Teaching Hospital

Accuracy of external cause-of-injury coding in VA polytrauma patient discharge records

Qualidade da informação sobre causas externas no Sistema de Informações Hospitalares

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