| Coding errors and the trauma patient--is nursing case management the solution? | |
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MedLine Citation:
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PMID: 12404969 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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The aim was to investigate the accuracy of clinical information coding and the financial consequence for trauma patients at a tertiary trauma centre using the resources of trauma nursing case managers. Clinical data for admitted trauma patients in August and September 2000 were compared with data routinely obtained by trauma case managers on their daily rounds. We audited patient injuries, in-hospital complications, investigations, and procedures. Clinical information records requiring alteration were returned to the clinical information manager with additional information and re-entered into the clinical information database. 100 trauma patient records (15% of admissions for 2000) were audited. 28% of recoded records had to have their diagnosis related group (DRG) changed, which resulted in the identification of additional funding of over $39,000. We conclude that the implementation of episode funding for acute episodes, such as the complex trauma patient, is placing increased importance on accuracy of coding. The validity of coding is dependent on legible, comprehensive and complete documentation and is improved dramatically by using nursing case manager patient progress summaries. |
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Authors:
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Kate Curtis; Louise Bollard; Cara Dickson |
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Publication Detail:
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Type: Journal Article |
Journal Detail:
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Title: Australian health review : a publication of the Australian Hospital Association Volume: 25 ISSN: 0156-5788 ISO Abbreviation: Aust Health Rev Publication Date: 2002 |
Date Detail:
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Created Date: 2002-10-30 Completed Date: 2003-01-02 Revised Date: 2004-11-17 |
Medline Journal Info:
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Nlm Unique ID: 8214381 Medline TA: Aust Health Rev Country: Australia |
Other Details:
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Languages: eng Pagination: 73-80 Citation Subset: H |
Affiliation:
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St George Hospital. |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Case Management* Database Management Systems / standards Documentation / standards* Episode of Care* Forms and Records Control / standards* Hospital Information Systems / standards Humans International Classification of Diseases Medical Records / classification* Medical Records Department, Hospital / organization & administration Medical Staff, Hospital / standards New South Wales Nursing Staff, Hospital* Quality Control Reimbursement Mechanisms Reproducibility of Results Software Trauma Centers / economics, organization & administration*, utilization Wounds and Injuries / classification*, economics |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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