title: Documentation and coding of medical records in a tertiary care center: a pilot study.
abstract: BACKGROUND
  Since the medical record is the major source of health information, it is necessary to maintain accurate, comprehensive and properly coded patient data. We reviewed 300 medical records from patients at King Faisal Specialist Hospital and Research Center, representing four departments (medicine, surgery, pediatrics and obstetrics and gynecology).
  
  
  METHODS
  The records were audited following the guidelines of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for accuracy and completeness of documentation and coding of primary and secondary diagnoses and procedures performed.
  
  
  RESULTS
  Of 1051 items abstracted, 876 (83.3%) were accurately documented, 41 (3.9%) were inaccurately documented, and 134 (12.7%) were not documented. Of the items abstracted, 736 (70%) were assigned a correct code, 110 (10.5%) were assigned an incorrect code, and 205 (19.5%) were not coded. More items classified as accurately documented were coded correctly (71.1%) than items inaccurately documented (49.7%) (P < 0.0001). The difference in comprehensiveness of documentation, which reflects physician performance, was not statistically significant among the four departments (P value < 0.234). The difference in the accuracy of coding, which reflects coder performance, was statistically significant (P value < 0.036).
  
  
  CONCLUSIONS
  Only 60% of the audited records met the benchmark for good quality medical records with regards to documentation and coding. A positive correlation between the accurate documentation and correct coding was noted, which supports the conclusion that high quality documentation enhances coding accuracy. These data, although encouraging, suggest room for improvement, which can be achieved through the collaboration of clinicians, who have extensive clinical experience, and coding professionals, who have comprehensive classification system expertise.
authors.affiliation: Department of Family Medicine and Polyclinics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia. jfarhan@kfshrc.edu.sa
authors.forename: Joman
authors.initials: J
authors.lastname: Farhan
authors.forename: Sulaiman
authors.initials: S
authors.lastname: Al-Jummaa
authors.forename: Abdulrahman A
authors.initials: AA
authors.lastname: Alrajhi
authors.forename: Abdulrahman
authors.initials: A
authors.lastname: Al-Rajhi
authors.forename: Hassan
authors.initials: H
authors.lastname: Al-Rayes
authors.forename: Abdulaziz
authors.initials: A
authors.lastname: Al-Nasser
mesh_terms: D004282:Documentation; D005568:Forms and Records Control; D006801:Humans; D008485:Medical Audit; D008499:Medical Records / Q000592:standards*; D008500:Medical Records Department, Hospital; D010865:Pilot Projects; D012529:Saudi Arabia