An audit of diagnostic coding in genitourinary medicine clinics. Trent Region Genitourinary Medicine Audit Group.
The KC60 diagnostic code information provides an epidemiological monitor of sexually transmitted infection (STI) and a means of standardizing clinical workload in genitourinary medicine (GUM) departments. We aimed to assess the coding process and its uniformity within the Trent region by means of a confidential self-administered coding exercise with simulated case presentations. The correct coding for STIs ranged from 59.4% to 100% in different scenarios. Difficulty was identified in the coding of vulvitis and balanitis where no organism was isolated, as represented by a wide range of codes. HIV pre-test counselling without testing was coded by only 57.8% of respondents. Over 95% indicated correctly the first hepatitis B vaccine dose but 21% failed to code once only for the course. Coding practice also varied within individual sites with a 21-100% discordance. In parts diagnostic accuracy was good but there were areas of non-uniformity both within sites and cross-regionally. Regional discussions have resulted in increased training opportunities and guidelines have been developed to increase uniformity and achieve consensus in uncertain areas.
Carlin
E M
EM
Department of Genitourinary Medicine, The King's Mill Centre for Health Care Services, Sutton-in-Ashfield, Nottinghamshire, UK.
Rogstad
K E
KE
D052776:Female Urogenital Diseases / Q000145:classification* / Q000175:diagnosis / Q000453:epidemiology; D005568:Forms and Records Control; D006748:Hospital Departments; D006801:Humans; D052801:Male Urogenital Diseases; D008499:Medical Records / Q000592:standards*; D012749:Sexually Transmitted Diseases / Q000145:classification* / Q000175:diagnosis / Q000453:epidemiology; D006113:United Kingdom / Q000453:epidemiology