The Relationship between Health Record Documentation and Clinical Coding

1. The Relationship between Health Record Documentation and Clinical Coding Lorraine Nicholson President of IFHRO (International Federation of Health Records Organisations) & Independent Health Records Consultant Co-Author: Sue Walker Director, National Centre for Health Information Research and Training, Australia HIMAA Conference, Perth, Australia 16th October 2009 HIMAA Conference 16/10/09

2. The Relationship between Health Record Documentation and Clinical Coding • Clinical coding is the translation of medical terminology as written by the clinician into a coded format which is nationally and internationally recognised • i.e. It is the translation into code of what has been documented by treating clinical staff • Coders should not make assumptions but should only code what is documented • The accuracy of clinical coding is dependent on the clinician recording clear and complete diagnostic and procedural information • Coding reflects the quality of the source documentation as well as the skills and knowledge of the coder. HIMAA Conference 16/10/09

3. Primary Purposes of Health Records (1) • Health Records are basic clinical tools • Accurate, complete and timely documentation in the record is the responsibility of clinician treating the patient • The primary purpose of the Health Record is to facilitate clinical care • The record acts as an ‘aide-memoire’ for the treating clinician & is an essential communication tool for other healthcare professionals • It facilitates the patient receiving appropriate treatment at the right time HIMAA Conference 16/10/09

4. Primary Purposes of Health Records (2) • Records provide a permanent account of diagnostic & treatment decisions & a means by which a clinician’s treatment can be judged • The record provides evidence of what was done, when & why • It also provides the means to answer questions about diagnosis & treatment & defend medico-legal claims where necessary HIMAA Conference 16/10/09

5. Secondary Purposes of Health Records To provide a dependable source of clinical data to support clinical audit, research, teaching, resource allocation and performance planning Clinical coding is the link between the primary and secondary purposes of the record HIMAA Conference 16/10/09

6. Existing Standards for Health Records There are two types of existing standards for Health Records • Structure of the Health Record • Content and completeness of the documentation within the record HIMAA Conference 16/10/09

7. Structure of the Health Record • Standards for organisation & configuration of Health Records are needed so that records are structured appropriately • Records are a chronological record of important events & need to be ordered appropriately so that relevant clinical information is recorded in the right place to enable clinicians to locate it quickly & easily when required HIMAA Conference 16/10/09

8. Content and Completeness of Documentation within the record Content and completeness standards apply to the format & definition of what is recorded in the agreed structure to ensure that: • Entries are legible • Authors of entries are attributable • Entries are dated, signed and timed • Amendments are made transparently • Entries are made contemporaneously whenever possible but as soon as possible after the event/encounter • There is limited use of abbreviations and jargon • Personal or subjective statements are not recorded • There is no documentation of value judgements and speculation • irrelevant documents are not included HIMAA Conference 16/10/09

9. Importance of Standards for Health Records Both types of standards for records are vitally important for clinical coding purposes • STRUCTURE - so that relevant information to determine complete & accurate codes can be easily located • CONTENT - because the completeness and accuracy of the coding relies on content HIMAA Conference 16/10/09

10. NHS Standards (England) • The Health Informatics Unit at the Royal College of Physicians (RCP) in London has coordinated the development and piloting of nationally agreed standards for the structure and content of Health Records that have been agreed for all hospital specialties • The project was funded by NHS Connecting for Health and the standards were ‘signed off’ in April 2008 by the Academy of Medical Royal Colleges • The standards were passed as fit for purpose • Psychiatry and Paediatrics - although the information that they require is different from and additional to that covered by the standardised headings, the requirements for these specialties can be accommodated within the proposed standards structure HIMAA Conference 16/10/09

11. EHR in the United Kingdom • England has a population of 60 million & is the largest of the four “home countries” of the UK (England, Scotland, Wales & Northern Ireland) • The National Health Service (NHS) in England had an overall budget for 2007/08 of £96billion • It is the largest employer in Europe & one of the largest in the world employing 1.3 million people • There are 600 NHS healthcare provider organisations • Over 35,000 different categories of treatment • Each home country has its own approach to the development & implementation of Electronic Health Records but this presentation focuses on EHR development in England HIMAA Conference 16/10/09

12. National EHR Development in England • National EHR development in England is the responsibility of NPfIT (£6.2 billion) • The NHS Care Records Service will provide 60 million NHS patients with an individual electronic NHS Care Record providing details of key treatments and care within the health service and/or the social care sector • There are two principal components to the electronic patient record programme for hospitals in England • The Summary Care Record (held nationally) • The Detailed Care Record (held locally). HIMAA Conference 16/10/09

13. On-Going Use of the Standards • The standards developed by the RCP have been submitted to NHS Connecting for Health which is responsible for the development of the national Electronic Health Record in England • Work on definitions that will meet the rigorous requirements for IT implementation is currently underway • The definitions will then be submitted to the NHS Information Standards Board for Health & Social Care for approval • All IT system suppliers to the NHS will be required to use the standards for their EPR solutions • Many hospitals & IT suppliers are already implementing them in both paper & electronic format HIMAA Conference 16/10/09

14. Supporting the Use of the RCP Standards Operationally The NHS Digital & Health Information Policy Directorate in England has published a two part clinician’s guide to the standards: Part 1 - Rationale for developing and introducing the national professional record keeping standards &s the expected benefits Part 2 - Generic Health Record Keeping Standards & the structure & content standards for admission, handover & discharge documents HIMAA Conference 16/10/09

15. Importance of Standards for Electronic Health Record Development • The implementation of EHR’s in the NHS significantly increases the importance of structured records & this applies to all EHR systems wherever they are implemented around the world • With the development of EHR’s there is an urgent need to standardise the structure & content of clinical information recorded & communicated through the Health Record HIMAA Conference 16/10/09

16. Standards to Ensure Safer & More Efficient & Effective Care • Structure & content standards are crucial to ensure that clinical information can be consistently stored, retrieved & shared between information systems • The standards must therefore be based on professional agreement that reflects best clinical practice • Standards must be incorporated into information systems by skilled IT professionals • Patients must also be involved at all stages of standards development HIMAA Conference 16/10/09

17. The Main Benefit of Structure & Content Standards in EHR Systems Clinical information in electronic health records will be recorded once, and made available when and where required, thus improving efficiency and saving time HIMAA Conference 16/10/09

18. Benefits of Standards for HIM’s & Coders Improves HIM’s & Coders ability to abstract comprehensive and relevant clinical information on which to assign the most complete and accurate set of codes to describe the clinical encounter HIMAA Conference 16/10/09

19. Standards & Coding Quality • ICD-10 contains recommended format for medical certificate of cause of death but many of the mortality coding rules have been developed to address issues caused by inadequate documentation of cases • Instructions for morbidity coding have been developed to manage poor documentation • Having standards for record structure and content would go some way to addressing poor documentation before it becomes a coding problem HIMAA Conference 16/10/09

20. Improving Coding Quality Globally • Availability of standards for Health Records (& potentially other source documents, such as death certificates) for use internationally would assist with the provision of high quality coded data • Most countries with well-developed health information systems already have their own standards • Small and developing countries in which there are few trained Health Record professionals may not have access to such standards HIMAA Conference 16/10/09

21. Improving Coding Quality Globally The authors of this paper suggest that a discussion about the development of simple, but comprehensive, standards for source documents be considered as another means to improving coding quality around the world HIMAA Conference 16/10/09

22. Thank You Lorraine Nicholson President of IFHRO l.nicholson@zen.co.uk +44 01706 355957 HIMAA Conference 16/10/09