eP117 The Accuracy of Clinical Coding in Electronic Patient Records Systems in Emergency General Surgery
Amina Yasmin, Christopher Yau, Anthony ChanAbstract
Introduction
Clinical coding is a process that converts healthcare information into a machine-readable format. Accurate coding is clinically essential as an integral part of the electronic patient record (EPR) as well as underpinning the data used for healthcare research, service planning and revenue. The nature of emergency general surgery (EGS), however, introduces coding challenges due to significant individual variation in clinical presentation and management. This audit evaluates the accuracy of clinical coding in EGS at a large UK acute tertiary centre.
Methods
A retrospective audit was designed to evaluate the accuracy of clinical coding of unselected EGS patients. A ‘gold standard’ coding for past medical (PMH) and surgical history (PSH) was defined for each patient by an experienced surgeon from any information available within the EPR. This standard was compared to the EPR coding, and clerking entries from both Emergency Department (ED) doctors and the admitting surgeon.
Results
Fifty patients admitted in January 2024 were included. On average, EPR coding contained 48% of PMH and PSH elements when compared to the gold standard. Clerking documents from ED doctors and admitting surgeons averaged 49% and 58% respectively. Drug history recorded in the EPR was concordant in 71% of patients compared to ED (47%) and surgical (53%) clerkings.
Conclusion
This audit highlights the need for quality improvement in clinical coding accuracy. The data transformation benefits of EPRs are well established but are dependent on good quality data input. Inaccurate coding can have wide ranging implications inside and outside the direct care setting.