title: The accuracy of real-time procedure coding by theatre nurses: a comparison with the central national system.
abstract: Accurate and timely clinical data are required for clinical and organisational purposes and is especially important for patient management, audit of surgical performance and the electronic health record. The recent introduction of computerised theatre management systems has enabled real-time (point-of-care) operative procedure coding by clinical staff. However the accuracy of these data is unknown. The aim of this Scottish study was to compare the accuracy of theatre nurses' real-time coding on the local theatre management system with the central Scottish Morbidity Record (SMR01). Paired procedural codes were recorded, qualitatively graded for precision and compared (n = 1038). In this study, real-time, point-of-care coding by theatre nurses resulted in significant coding errors compared with the central SMR01 database. Improved collaboration between full-time coders and clinical staff using computerised decision support systems is suggested.
authors.affiliation: Wishaw General Hospital, Wishaw, UK. donald.maclean@lanarkshire.scot.nhs.uk
authors.forename: Donald
authors.initials: D
authors.lastname: Maclean
authors.forename: Hakim Ben
authors.initials: HB
authors.lastname: Younes
authors.forename: Margaret
authors.initials: M
authors.lastname: Forrest
authors.forename: Hazel K
authors.initials: HK
authors.lastname: Towers
mesh_terms: D059019:Clinical Coding / Q000592:standards*; D016208:Databases, Factual; D017598:Efficiency, Organizational; D006753:Hospital Records; D006801:Humans; D008499:Medical Records; D016347:Medical Records Systems, Computerized / Q000639:trends; D009017:Morbidity; D015399:Nursing Research; D009871:Operating Room Nursing; D019095:Point-of-Care Systems; D011361:Professional Competence; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies; D012606:Scotland