Clinical documentation requirements for the accurate coding of hospital-acquired urinary tract infections in Australia
Sue Liu
A * , Daniel Kim B , Samuel Penfold C and Andrea Doric B
A Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Vic. 3800, Australia.
B Department of Quality Planning and Innovation, Eastern Health, Melbourne, Vic. 3128, Australia.
C School of Clinical Sciences, Monash Health, Clayton, Vic. 3168, Australia.
Australian Health Review 46(6) 742-745 https://doi.org/10.1071/AH22155
Submitted: 1 June 2022 Accepted: 13 September 2022 Published: 13 October 2022
© 2022 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA.
Abstract
Aims We evaluated the accuracy of medical coders in distinguishing the aetiology of urinary tract infection according to clinical documentation.
Methods The clinical documentation of patients coded as having had a hospital-acquired urinary tract infection from January to June 2020 at two Melbourne hospitals were assessed for community or hospital acquisition.
Results We found that 48.89% of cases were inaccurately categorised as hospital-acquired, due to insufficient detail in clinical documentation. Risk factors for hospital-acquired urinary tract infection were present in at least 30% of correctly categorised cases.
Conclusions Clinical documentation is not filled out with sufficient detail or in a timely enough manner for clinical coders to distinguish between hospital or community origin.
Keywords: clinical coding, clinical documentation, health information management, hospital-acquired complications, hospital-acquired urinary tract infection, surveillance, urinary tract infection, Victoria.
References
[1] Australian Commission on Safety and Quality in Health Care. Hospital-Acquired Complications Information Kit. Sydney: ACSQHC; 2018.[2] Duke GJ, Moran JL, Bersten AD, Bihari S, Roodenburg O, Karnon J, et al. Hospital-acquired complications: the relative importance of hospital- and patient-related factors. Med J Aust 2021; 216 242–7.
| Hospital-acquired complications: the relative importance of hospital- and patient-related factors.Crossref | GoogleScholarGoogle Scholar |
[3] Lydeamore MJ, Mitchell BG, Bucknall T, Cheng AC, Russo PL, Stewardson AJ. Burden of five healthcare associated infections in Australia. Antimicrob Resist Infect Control 2022; 11 69
| Burden of five healthcare associated infections in Australia.Crossref | GoogleScholarGoogle Scholar |
[4] Group GRIC. Is it a UTI? Department of Health; 2019. Available at https://www.vicniss.org.au/media/2088/is-it-a-uti_book-2019-3.pdf
[5] Goto M, Ohl ME, Schweizer ML, Perencevich EN. Accuracy of administrative code data for the surveillance of healthcare-associated infections: a systematic review and meta-analysis. Clin Infect Dis 2014; 58 688–96.
| Accuracy of administrative code data for the surveillance of healthcare-associated infections: a systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar |
[6] Mitchell BG, Ferguson JK. The use of clinical coding data for the surveillance of healthcare-associated urinary tract infections in Australia. Infect Dis Health 2016; 21 32–5.
| The use of clinical coding data for the surveillance of healthcare-associated urinary tract infections in Australia.Crossref | GoogleScholarGoogle Scholar |
[7] Independent Hospital Pricing Authority. Pricing Framework for Australian Public Hospital Services 2020–21. Independent Hospital Pricing Authority; 2019.
[8] Michel JL, Cheng D, Jackson TJ. Comparing the coding of complications in Queensland and Victorian admitted patient data. Aust Health Rev 2011; 35 245–52.
| Comparing the coding of complications in Queensland and Victorian admitted patient data.Crossref | GoogleScholarGoogle Scholar |
[9] Hanson JL, Stephens MB, Pangaro LN, Gimbel RW. Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research. BMC Health Serv Res 2012; 12 407
| Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research.Crossref | GoogleScholarGoogle Scholar |
[10] Abdelrahman W, Abdelmageed A. Medical record keeping: clarity, accuracy, and timeliness are essential. BMJ 2014; 348 f7716
| Medical record keeping: clarity, accuracy, and timeliness are essential.Crossref | GoogleScholarGoogle Scholar |
[11] Independent Hospital Pricing Authority. Pricing and funding for safety and quality – Risk adjustment model for hospital acquired complications – March 2022. Independent Hospital Pricing Authority; 2022.
[12] Independent Hospital Pricing Authority. Pricing and funding for safety and quality. Risk adjustment model for hospital acquired complications. Version 3. 2018. Available at https://www.ihpa.gov.au/sites/default/files/publications/pricing_and_funding_for_safety_and_quality_‐_risk_adjustment_model_for_hospital_acquired_complications_2018‐19.pdf [verified 13 November 2020]
[13] National Centre for Classification in Health. The International statistical classification of diseases and related health problems, 10th revision, Australian modification (ICD-10-CM), 1st edn. Sydney: National Centre for Classification in Health; 1998.
[14] Tang PC, LaRosa MP, Gorden SM. Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions. J Am Med Inform Assoc 1999; 6 245–51.
| Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions.Crossref | GoogleScholarGoogle Scholar |
[15] Kuperman GJ, Gibson RF. Computer physician order entry: benefits, costs, and issues. Ann Intern Med 2003; 139 31–9.
| Computer physician order entry: benefits, costs, and issues.Crossref | GoogleScholarGoogle Scholar |
[16] Duke GJ, Shann F, Knott CI, Oberender F, Pilcher DV, Roodenburg O, et al. Hospital-acquired complications in critically ill patients. Crit Care Resusc 2021; 23 285–91.
| Hospital-acquired complications in critically ill patients.Crossref | GoogleScholarGoogle Scholar |
