مرور نظامند کیفیت کدگذاری تشخیص‌ها و اقدامات درمانی و عوامل موثر بر آن در ایران
محورهای موضوعی : -مدارک پزشکی
1 - دانشجو-دانشگاه علوم پزشکی ایران
2 - استاد، مدیریت اطلاعات سلامت، گروه مدیریت اطلاعات سلامت، دانشکده مدیریت و اطلاع رسانی پزشکی، دانشگاه علوم پزشکی ایران، تهران، ایران
کلید واژه: کیفیت داده‌ها, بیمارستان, مرور نظامند, کدگذاری بالینی,
چکیده مقاله :
مقدمه: یکی از چالش‌های همیشگی در ارتباط با کدگذاری تشخیص‌ها و اقدامات درمانی، کیفیت داده‌های حاصل از کدگذاری، است. صحت، پایایی، بهنگامی و کامل بودن، همگی از مؤلفه‌های کیفیت کدگذاری هستند. هدف این مطالعه بررسی پژوهش‌های انجام شده در خصوص کیفیت کدگذاری تشخیص‌ها و اقدامات درمانی و عوامل موثر بر آن در ایران، بود. روش پژوهش: این پژوهش، یک مطالعه مروری نظامند است، که در آن تمامی مقالات چاپ شده مربوط به موضوع تحقیق در بازه زمانی فرودین 1380 تا پایان اسفند 1394 (مارس2001 تا مارس 2015) مورد بررسی قرار گرفتند. به منظور یافتن مقالات جستجوی اینترنتی در پایگاه‌های داخلیMagiran ،Barakat Knowladege Network System ،Irandoc ، SID و پایگاه‌های خارجیGoogle scholar، Science Directو PubMed و با کلیدواژه‌های فارسی و انگلیسی صورت گرفت. 200 مقاله چاپ شده به زبان فارسی و انگلیسی بازیابی شد و در نهایت 14 مقاله مرتبط شناخته شد و مورد بررسی قرار گرفت. یافته‌ها: چهار مقاله به طور اختصاصی به بررسی مؤلفه‌های کیفیت کدگذاری، شش مقاله به بررسی عوامل موثر بر کیفیت کدگذاری، و چهار مقاله نیز به صورت مشترک هر دو موضوع مؤلفه‌ها و عوامل موثر بر کیفیت کدگذاری را بررسی کرده بودند. از مؤلفه‌های کیفیت کدگذاری، بیشتر مطالعات (هفت مورد) صحت کدگذاری را مورد بررسی قرار داده بودند. در خصوص عوامل موثر بر کیفیت کدگذاری، بیشتر مطالعات (پنج مورد) به بررسی نقش اصول مستندسازی و تشخیص‌نویسی پرداخته بودند. نتیجه‌گیری: در مجموع یافته‌های مطالعه نشان داد که از بین مؤلفه‌های کیفیت کدگذاری ویژگی بهنگامی از وضعیت مطلوبی برخوردار نیست. در خصوص عوامل موثر بر کیفیت کدگذاری یافته‌های مطالعه نشان‌دهنده اهمیت نقش رعایت اصول مستندسازی در کیفیت کدگذاری است.
Introduction: One of the perennial challenges associated with coding diagnoses and treatment, quality data encryption is. Accuracy, reliability, completeness timed and all the components are coding quality. The aim of this study was to evaluate studies on the quality of diagnostic coding and medical care and its determinants in Iran, respectively. Methods: This study is a systematic review, in which all articles published on the topic in the lower period 1380 to the end of March 1394 (March 2001 to March 2015) were studied. Internet search to find articles in the internal data base Magiran, BarakatKnowladege Network System, Irandoc, SID and external databases, Google scholar, Science Direct and PubMed and was Persian and English keywords. 200 articles published in Farsi and English were retrieved and finally 14 articles were identified and evaluated. Results: Four paper specifically examines the components of quality of coding, six paper examines the factors affecting coding quality, and the four paper also common for both components and factorsaffecting coding quality were examined. Component coding quality, most studies (seven cases) were examined coding accuracy. The factors affecting coding quality, most studies (five cases) to investigate the role of documentation and diagnosis recording among, respectively. Conclusion: The results of the study showed that among the components of quality timeliness of coding properties is not desirable. Findings of the study on factors affecting coding quality is the importance of observing principles of documentation on coding quality.
1- Safdari R. Nomenclature and Classification Systems of Diseases and Presenting a Model for national classification of diseases. Tehran: Mirmah Press; 2003. [In Persian]
2- Improving clinical coding: Royal collage of physician; 2014 [cited 2015 5 May]. Available from: https://www.rcplondon.ac.uk/projects/improving-clinical-coding.
3- Olewicz T. Benefits of Clinical Coding in Healthcare: Resip Drug Database UK Ltd; 2014 [cited 2015 20 May]. Available from: http://www.resip.co.uk/news/benefits-clinical-coding-healthcare.
4- Skurka MA. Health information management: principles and organization for health information services: John Wiley & Sons; 2012.
5- De Lusignan S. The barriers to clinical coding in general practice: a literature review. Informatics for Health and Social Care 2005; 30(2): 89-97.
6- Shepheard J. Health information management and clinical coding workforce issues. Health Information Management Journal 2010; 39(3): 37.
7- Alipour J, Ahmadi M. Adherence to quality elements for coding of diagnoses and procedures. Hakim Research Journal 2009; 12(1): 36-40. [In Persian]
7- Moghaddasi H, Rabiei R, Sadeghi N. Improving the quality of clinical coding: a comprehensive audit model. Journal of Health Management and Informatics 2014; 1(2): 36-40.
8- Abdelhak M, Grostick S, Hanken MA, Jacobs E. Health information. Managing a Strategic Resource, 2nd edn Philadelphia, PA: WB Saunders; 2001.
9- Avila-Weil D, Regan R. Independent Medical Coding: The Comprehensive Guidebook for Career Success as a Medical Coder: Rayve Productions; 2007.
10- Williams D. Clinical Coding: . Wales: Betsi Cadwaladr University Health Board; 2012.
11- Zare Fazlollahi Z, Khoshkalam Aghdam M, Lotfnezhad Afshar H, Jabraili M. The Survey of the Rate of Complete and Adequate Diagnosis Writing at Inpatien t’s Records with Fracture, Urmia Motahari Hospital. Health Information Management Journal 2011; 8(3): 406-11.
12- Cunningham J, Williamson D, Robinson KM, Carroll R, Buchanan R, Paul L. The quality of medical record documentation and'external cause'of fall injury coding in a tertiary teaching hospital. Health Information Management Journal. 2014;43(1):6.
13- Danzi JT, Masencup B, Brucker MA, Dixon-Lee C. Case study: clinical documentation improvement program supports coding accuracy. Topics in health information management. 2000;21(2):24-9.
14- Price E, Robinson K. Professional Practice and Innovation: The Coding Masterpiece-a Framework for the Formal Pathways and Processes of Health Classification. Health Information Management Journal 2011; 40(1): 14.
15- AHIMA. Coding Specialist 2006 [cited 2015 18 May]. Available from: http://www.ahima.org/coding/coding_specialist.asp.
16- Santos S, Murphy G, Baxter K, Robinson KM. Organisational factors affecting the quality of hospital clinical coding. Health Information Management Journal 2008; 37(1): 25-35.
17- Mahmoodian S, Ahmadi M, Hosseini F. Vision in Practice: Clinical Coding Policy and Procedure. Journal of Health Administration 2008; 11(31): 47-54. [In Persian]
18- Ahmadi M, Shahmoradi L, Hoseini M, Bagherzadeh R. What are the medical coding software requirements? Shiraz E Medical Journal 2010; 11(4): 225-43.
19- Akhondzade R. Health system transformation project, an opportunity or a threat for doctors (Editorial). Journal of Anesthesiology and Pain 2014; 5(1): 1-2. [ In Persian]
20- Hospital accreditation standards in Iran. Tehran: Ministery of Health & Education; 2014.
21- Zarei J. Developing framework for standardization clinical diagnos coding for hospitals based on ICD. [Report pdf APW].WHO Representative Office in IR Iran; 2015.
22- The quality of clinical coding in the NHS. Capita Health and Wellbeing Limited,England; 2014.
23- Burns EM, Rigby E, Mamidanna R, Bottle A, Aylin P, Ziprin P, et al. Systematic review of discharge coding accuracy. Journal of Public Health 2012; 34(1): 138-48.
24- Ahmadi M, Khoushkam M, Alipour J. A comparative study on adhering degree of diseases and procedures coding quality elements in teaching hospitals of Iran, Tehran, and Shaheed Beheshti Universities of Medical Sciences. Journal of Health Administration 2007; 10(27): 13-8. [In Persian]
25- Hayavi Haghighi M, Dehghani M, Khorrami F, Alipour J. Accuracy Rate of Underlying Cause of Death Coding in Educational Hospitals of Bandar Abbas, Iran. Health Information Management 2013; 10(3): 411-20. [In Persian]
26- Abbaspour R, Langarizadeh M, Ahmadi M. A Comparison of Coding Quality for Burn Injuries in Deceased and Non-Deceased Patients' Records. Health Information Management 2013; 10(5): 691. [In Persian]
27- Alipour J, Karimi A, Erfannia L, Shahrakipour M, Hayavi Haghighi M, Kadkhoda A. Reliability of Medical Diagnosis with International Classification of Diseases 10th Version in 2011. Health Information Management 2013; 10(1): 1-9. [In Persian]
28- Akhlaghi F, Raeisi P, Kazemi SM. Rate of Implementation of Standard Codes for Injuries, Burns and Poisonings in Teaching-Hospitals of the Iran, Tehran and Shahid Beheshti Medical Universities. Health information management 2009; 1(6): 23-34. [In Persian]
29- Jahanbakhsh M, Saghaeyannejad S. Survey of Coder's Knowledge about Coding Guidelines in Hospitals in Isfahan. Health information management 2010; 7(1): 75-82. [In Persian]
30- Rezayi Mofrad MR, Rangraz Jeddi F, Rangraz Jeddi M. Adequacy of Data on Injuries' External Causes for Coding Based on ICD-10 in Inpatient Medical Records and Emergency Wards of Shahid Beheshti Hospital In Kashan. Payavard Salamat 2011; 5(3): 10-9. [In Persian]
31- Farzandipour M, Sheikhtaheri A. Accuracy of diagnostic coding based on ICD-10. Feyz Journals of Kashan University of Medical Sciences 2009; 12(4): 67-76. [In Persian]
32- Farzandipour M, Sheikhtaheri A, Shokrizadeh Arani L. Accuracy of Procedure Codes Based on ICD9CM. Health Information Management 2011; 7(4): 410-22. [In Persian]
33- Saghaeiannejad S, Ehteshami A, Kasaei M, Shokrani S. Study of complying with principles of burn diagnosis recording and coding in Imam Musa Kazim hospital according to the ICD-10 instructions. International Journal of Health System and Disaster Management 2013; 1(2): 78.
34- Bajaj Y, Crabtree J, Tucker A. Clinical coding: how accurately is it done? Clinical Governance: An International Journal 2007; 12(3): 159-69.
35- Farhan J, Al-Jummaa S, Alrajhi A, Al-Rayes H, Al-Nasser A. Documentation and coding of medical records in a tertiary care center: a pilot study. Ann Saudi Med 2005; 25(1): 46-9.
36- Cheng P, Gilchrist A, Robinson KM, Paul L. The risk and consequences of clinical miscoding due to inadequate medical documentation: a case study of the impact on health services funding. Health Information Management Journal 2009; 38(1): 35.
37- Stareh M, Baghrian-Mahmoudabadi H, Amini F, Rafait Y, Arjmankia A. A Study on the Frequency of Medical History Sheet, Operation Report Sheet and Physician Order Sheet Completeness by Different Documentaries in Isfahan Teaching Hospitals, 2007-8. Iranian Journal of Forensic Medicine 2010; 15(14): 244-51.[In Persian]
38- Mashoufi M, Rostami K, Mardi A. Documentation of Medical Records by Physicians in the Hospitals under Ardabil University of Medical Sciences, 2001. Journal of Ardabil University of Medical Sciences 2006; 6(1): 73-7. [In Persian]
39- Mahjob MP, Farahabadi SME, Dalir M. Evaluation of Randomly Selected Completed Medical Records Sheets in Teaching Hospitals of Jahrom University of Medical Sciences, 2009. Journal of Fasa University of Medical Sciences 2011; 1(1): 20-8. [In Persian]
40- Sharifian R, Ghazisaeedi M. Information registration in surgical special sheets for discharege patients in Tehran University of Medical Sciences Teaching Hospitals, 2005. Payavard Salamat 2008; 2(1): 31-9. [In Persian]
41- Esmailian M, Nasr-Esfahani M. The Quality of Patients’ Files Documentation in Emergency Department; a Cross Sectional Study. Iranian Journal of Emergency Medicine 2014; 1(1): 16-21. [In Persian]
42- Carr E, Pillai A. Improving clinical coding accuracy. Annals of The Royal College of Surgeons of England 2010; 92(1): 87.
43- McKenzie K, Walker SM, Dixon-Lee C, Dear G, Moran-Fuke J. Clinical coding internationally: a comparison of the coding workforce in Australia, America, Canada and England; 2004.
44- McKenzie K, Walker SM, Klisanin A, Spallek M. The Australian Coder Workforce Survey 2002-Coders’ responses. Coding matters 2003; 10(1): 14-7.
45- Farzandipour M, Meidani Z. Do hospital information systems vendors meet user needs. Director General 2011; 8(4): 545-53. [In Persian]
_||_1- Safdari R. Nomenclature and Classification Systems of Diseases and Presenting a Model for national classification of diseases. Tehran: Mirmah Press; 2003. [In Persian]
2- Improving clinical coding: Royal collage of physician; 2014 [cited 2015 5 May]. Available from: https://www.rcplondon.ac.uk/projects/improving-clinical-coding.
3- Olewicz T. Benefits of Clinical Coding in Healthcare: Resip Drug Database UK Ltd; 2014 [cited 2015 20 May]. Available from: http://www.resip.co.uk/news/benefits-clinical-coding-healthcare.
4- Skurka MA. Health information management: principles and organization for health information services: John Wiley & Sons; 2012.
5- De Lusignan S. The barriers to clinical coding in general practice: a literature review. Informatics for Health and Social Care 2005; 30(2): 89-97.
6- Shepheard J. Health information management and clinical coding workforce issues. Health Information Management Journal 2010; 39(3): 37.
7- Alipour J, Ahmadi M. Adherence to quality elements for coding of diagnoses and procedures. Hakim Research Journal 2009; 12(1): 36-40. [In Persian]
7- Moghaddasi H, Rabiei R, Sadeghi N. Improving the quality of clinical coding: a comprehensive audit model. Journal of Health Management and Informatics 2014; 1(2): 36-40.
8- Abdelhak M, Grostick S, Hanken MA, Jacobs E. Health information. Managing a Strategic Resource, 2nd edn Philadelphia, PA: WB Saunders; 2001.
9- Avila-Weil D, Regan R. Independent Medical Coding: The Comprehensive Guidebook for Career Success as a Medical Coder: Rayve Productions; 2007.
10- Williams D. Clinical Coding: . Wales: Betsi Cadwaladr University Health Board; 2012.
11- Zare Fazlollahi Z, Khoshkalam Aghdam M, Lotfnezhad Afshar H, Jabraili M. The Survey of the Rate of Complete and Adequate Diagnosis Writing at Inpatien t’s Records with Fracture, Urmia Motahari Hospital. Health Information Management Journal 2011; 8(3): 406-11.
12- Cunningham J, Williamson D, Robinson KM, Carroll R, Buchanan R, Paul L. The quality of medical record documentation and'external cause'of fall injury coding in a tertiary teaching hospital. Health Information Management Journal. 2014;43(1):6.
13- Danzi JT, Masencup B, Brucker MA, Dixon-Lee C. Case study: clinical documentation improvement program supports coding accuracy. Topics in health information management. 2000;21(2):24-9.
14- Price E, Robinson K. Professional Practice and Innovation: The Coding Masterpiece-a Framework for the Formal Pathways and Processes of Health Classification. Health Information Management Journal 2011; 40(1): 14.
15- AHIMA. Coding Specialist 2006 [cited 2015 18 May]. Available from: http://www.ahima.org/coding/coding_specialist.asp.
16- Santos S, Murphy G, Baxter K, Robinson KM. Organisational factors affecting the quality of hospital clinical coding. Health Information Management Journal 2008; 37(1): 25-35.
17- Mahmoodian S, Ahmadi M, Hosseini F. Vision in Practice: Clinical Coding Policy and Procedure. Journal of Health Administration 2008; 11(31): 47-54. [In Persian]
18- Ahmadi M, Shahmoradi L, Hoseini M, Bagherzadeh R. What are the medical coding software requirements? Shiraz E Medical Journal 2010; 11(4): 225-43.
19- Akhondzade R. Health system transformation project, an opportunity or a threat for doctors (Editorial). Journal of Anesthesiology and Pain 2014; 5(1): 1-2. [ In Persian]
20- Hospital accreditation standards in Iran. Tehran: Ministery of Health & Education; 2014.
21- Zarei J. Developing framework for standardization clinical diagnos coding for hospitals based on ICD. [Report pdf APW].WHO Representative Office in IR Iran; 2015.
22- The quality of clinical coding in the NHS. Capita Health and Wellbeing Limited,England; 2014.
23- Burns EM, Rigby E, Mamidanna R, Bottle A, Aylin P, Ziprin P, et al. Systematic review of discharge coding accuracy. Journal of Public Health 2012; 34(1): 138-48.
24- Ahmadi M, Khoushkam M, Alipour J. A comparative study on adhering degree of diseases and procedures coding quality elements in teaching hospitals of Iran, Tehran, and Shaheed Beheshti Universities of Medical Sciences. Journal of Health Administration 2007; 10(27): 13-8. [In Persian]
25- Hayavi Haghighi M, Dehghani M, Khorrami F, Alipour J. Accuracy Rate of Underlying Cause of Death Coding in Educational Hospitals of Bandar Abbas, Iran. Health Information Management 2013; 10(3): 411-20. [In Persian]
26- Abbaspour R, Langarizadeh M, Ahmadi M. A Comparison of Coding Quality for Burn Injuries in Deceased and Non-Deceased Patients' Records. Health Information Management 2013; 10(5): 691. [In Persian]
27- Alipour J, Karimi A, Erfannia L, Shahrakipour M, Hayavi Haghighi M, Kadkhoda A. Reliability of Medical Diagnosis with International Classification of Diseases 10th Version in 2011. Health Information Management 2013; 10(1): 1-9. [In Persian]
28- Akhlaghi F, Raeisi P, Kazemi SM. Rate of Implementation of Standard Codes for Injuries, Burns and Poisonings in Teaching-Hospitals of the Iran, Tehran and Shahid Beheshti Medical Universities. Health information management 2009; 1(6): 23-34. [In Persian]
29- Jahanbakhsh M, Saghaeyannejad S. Survey of Coder's Knowledge about Coding Guidelines in Hospitals in Isfahan. Health information management 2010; 7(1): 75-82. [In Persian]
30- Rezayi Mofrad MR, Rangraz Jeddi F, Rangraz Jeddi M. Adequacy of Data on Injuries' External Causes for Coding Based on ICD-10 in Inpatient Medical Records and Emergency Wards of Shahid Beheshti Hospital In Kashan. Payavard Salamat 2011; 5(3): 10-9. [In Persian]
31- Farzandipour M, Sheikhtaheri A. Accuracy of diagnostic coding based on ICD-10. Feyz Journals of Kashan University of Medical Sciences 2009; 12(4): 67-76. [In Persian]
32- Farzandipour M, Sheikhtaheri A, Shokrizadeh Arani L. Accuracy of Procedure Codes Based on ICD9CM. Health Information Management 2011; 7(4): 410-22. [In Persian]
33- Saghaeiannejad S, Ehteshami A, Kasaei M, Shokrani S. Study of complying with principles of burn diagnosis recording and coding in Imam Musa Kazim hospital according to the ICD-10 instructions. International Journal of Health System and Disaster Management 2013; 1(2): 78.
34- Bajaj Y, Crabtree J, Tucker A. Clinical coding: how accurately is it done? Clinical Governance: An International Journal 2007; 12(3): 159-69.
35- Farhan J, Al-Jummaa S, Alrajhi A, Al-Rayes H, Al-Nasser A. Documentation and coding of medical records in a tertiary care center: a pilot study. Ann Saudi Med 2005; 25(1): 46-9.
36- Cheng P, Gilchrist A, Robinson KM, Paul L. The risk and consequences of clinical miscoding due to inadequate medical documentation: a case study of the impact on health services funding. Health Information Management Journal 2009; 38(1): 35.
37- Stareh M, Baghrian-Mahmoudabadi H, Amini F, Rafait Y, Arjmankia A. A Study on the Frequency of Medical History Sheet, Operation Report Sheet and Physician Order Sheet Completeness by Different Documentaries in Isfahan Teaching Hospitals, 2007-8. Iranian Journal of Forensic Medicine 2010; 15(14): 244-51.[In Persian]
38- Mashoufi M, Rostami K, Mardi A. Documentation of Medical Records by Physicians in the Hospitals under Ardabil University of Medical Sciences, 2001. Journal of Ardabil University of Medical Sciences 2006; 6(1): 73-7. [In Persian]
39- Mahjob MP, Farahabadi SME, Dalir M. Evaluation of Randomly Selected Completed Medical Records Sheets in Teaching Hospitals of Jahrom University of Medical Sciences, 2009. Journal of Fasa University of Medical Sciences 2011; 1(1): 20-8. [In Persian]
40- Sharifian R, Ghazisaeedi M. Information registration in surgical special sheets for discharege patients in Tehran University of Medical Sciences Teaching Hospitals, 2005. Payavard Salamat 2008; 2(1): 31-9. [In Persian]
41- Esmailian M, Nasr-Esfahani M. The Quality of Patients’ Files Documentation in Emergency Department; a Cross Sectional Study. Iranian Journal of Emergency Medicine 2014; 1(1): 16-21. [In Persian]
42- Carr E, Pillai A. Improving clinical coding accuracy. Annals of The Royal College of Surgeons of England 2010; 92(1): 87.
43- McKenzie K, Walker SM, Dixon-Lee C, Dear G, Moran-Fuke J. Clinical coding internationally: a comparison of the coding workforce in Australia, America, Canada and England; 2004.
44- McKenzie K, Walker SM, Klisanin A, Spallek M. The Australian Coder Workforce Survey 2002-Coders’ responses. Coding matters 2003; 10(1): 14-7.
45- Farzandipour M, Meidani Z. Do hospital information systems vendors meet user needs. Director General 2011; 8(4): 545-53. [In Persian]