title: Coding errors and the trauma patient--is nursing case management the solution?
abstract: 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.
authors.affiliation: St George Hospital.
authors.forename: Kate
authors.initials: K
authors.lastname: Curtis
authors.forename: Louise
authors.initials: L
authors.lastname: Bollard
authors.forename: Cara
authors.initials: C
authors.lastname: Dickson
mesh_terms: D019090:Case Management; D003628:Database Management Systems / Q000592:standards; D004282:Documentation / Q000592:standards*; D017050:Episode of Care; D005568:Forms and Records Control / Q000592:standards*; D006751:Hospital Information Systems / Q000592:standards; D006801:Humans; D038801:International Classification of Diseases; D008499:Medical Records / Q000145:classification*; D008500:Medical Records Department, Hospital / Q000458:organization & administration; D008505:Medical Staff, Hospital / Q000592:standards; D009517:New South Wales; D009741:Nursing Staff, Hospital; D011786:Quality Control; D012051:Reimbursement Mechanisms; D015203:Reproducibility of Results; D012984:Software; D014193:Trauma Centers / Q000191:economics / Q000458:organization & administration* / Q000706:statistics & numerical data; D014947:Wounds and Injuries / Q000145:classification* / Q000191:economics