The role of health classifications in health information management

Shepheard, Jennie; Groom, Andrea

doi:10.1177/1833358320905970

Cited by 3 publications

(4 citation statements)

References 31 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The integrity of clinical documentation is also critical for DRG reporting and other requirements and optimisation of coding and DRG groups at this level has significant second-level implications, including financial. In their editorial on the role of health classifications in health information management, Shepheard and Groom (2020: 85) made the point that DRGs developed from the analysis of the clinical codes in administrative databases are one of the most high-profile uses of clinically coded data. Research by Alonso et al (2020) clearly demonstrated how quality data resulted in more accurate payments, whereas Hay et al (2020) also drew attention to the association between CDI and improved quality and patient safety outcomes as well as increased hospital reimbursement and funding.…”

Section: Virtual Special Issue On CDImentioning

confidence: 99%

See 1 more Smart Citation

Clinical documentation integrity: Its role in health data integrity, patient safety and quality outcomes and its impact on clinical coding and health information management

Davis,

Shepheard

2023

HIM J

Self Cite

View full text Add to dashboard Cite

Clinical documentation has been defined as "information that is recorded about a person's care. The primary purpose of clinical documentation is to facilitate, safe, high quality and continuous care. . .and is stored within a health record" (Australian Commission on Safety and Quality in Healthcare, 2023). It needs to accurately reflect clinical events and decision-making for purposes of care continuity and communication. However, the quality and utility of clinical documentation has influence well beyond its primary purpose of supporting patient care. The World Health Organization has defined data integrity as:The degree to which data are complete, consistent, accurate, trustworthy, and reliable and that these characteristics of the data are maintained throughout the data life cycle. The data should be collected and maintained in a secure manner, such that they are attributable, legible, contemporaneously recorded, original or a true copy and accurate. Assuring data integrity requires appropriate quality and risk management systems, including adherence to sound scientific principles and good documentation practices (World Health Organization, 2016; cited in Victorian Agency for Health Information, 2018).

show abstract

Section: Virtual Special Issue On CDImentioning

confidence: 99%

“…In Australia, it includes the assignment of standardised International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modified (ICD-10-AM) and Australian Classification of Health Intervention codes (Shepheard and Groom, 2020), which substantially contribute to administrative datasets.…”

mentioning

confidence: 99%

Clinical documentation integrity: Its role in health data integrity, patient safety and quality outcomes and its impact on clinical coding and health information management

Davis,

Shepheard

2023

HIM J

Self Cite

View full text Add to dashboard Cite

show abstract

“…1,2 Moreover, health classifications play an important role in the integrity of coded data and the ability to deliver the requirements of information users. 3 Since the accuracy and quality of these data are very imperative, previous studies have focused on the evaluation of validity and reliability of clinical coding in medical records and the associated contributing factors. [4][5][6][7][8][9][10][11][12][13][14] However, previous studies report highly diverse findings.…”

Section: Introductionmentioning

confidence: 99%

“…Among other applications, these are particularly useful for the processing of reimbursements, clinical and epidemiological studies, quality care reporting and disease surveillance and monitoring 1,2 . Moreover, health classifications play an important role in the integrity of coded data and the ability to deliver the requirements of information users 3 . Since the accuracy and quality of these data are very imperative, previous studies have focused on the evaluation of validity and reliability of clinical coding in medical records and the associated contributing factors 4–14 .…”

Section: Introductionmentioning

confidence: 99%

Factors affecting the quality of diagnosis coding data with a triangulation view: A qualitative study

Hosseini

Kimiafar

Mostafavi

et al. 2021

Health Planning & Management

View full text Add to dashboard Cite

Objective: The most important challenge in utilizing medical record codes is the quality of coding data. The present study aims to investigate factors affecting the quality of diagnosis coding from different aspects covering different stakeholders in a multi-dimensional approach. Methods: First, we used Conventional Content Analysis to maximally gather all effective factors. As such, semistructured interviews were conducted with medical record coders (N = 32) at the referral hospitals in Mashhad, Iran. Second, 86 hospital staff members from 25 provinces were surveyed using a web-based questionnaire. Finally, a focus group discussion was conducted among coders (N = 18) in different hospitals across the country. Results: In general, the barriers to quality of inpatient record coding can be classified into three categories: (I) physician-related, (II) coder-related, and (III) managerial, financial and administrative factors. Conclusion: A triangulation view (related to coders, physicians as well as managerial, financial and administrative dimensions) could be used to identify the barriers affecting the quality of diagnosis coding data. The results of this study may help policymakers in development and implementation of appropriate strategies and effective interventions to improve the quality of clinical coding.

show abstract

Trans-ARPG: Automated ICD Coding method based on Adversarial Reinforcement Path Generation and Transformer mechanism

Zhang,

Liu

2023

2023 International Conference on Frontiers of Robotics and Software Engineering (FRSE)

View full text Add to dashboard Cite

The role of health classifications in health information management

Cited by 3 publications

References 31 publications

Clinical documentation integrity: Its role in health data integrity, patient safety and quality outcomes and its impact on clinical coding and health information management

Clinical documentation integrity: Its role in health data integrity, patient safety and quality outcomes and its impact on clinical coding and health information management

Factors affecting the quality of diagnosis coding data with a triangulation view: A qualitative study

Trans-ARPG: Automated ICD Coding method based on Adversarial Reinforcement Path Generation and Transformer mechanism

Contact Info

Product

Resources

About