G560(P) A service improvement project of Paediatric discharge letter diagnosis and its effect on clinical coding

Context Staff group involved: Consultant paediatricians Junior doctors Paediatric clinical coders and paediatrics business intelligence managers Medical students Problem It was brought to our attention in July 2014 by clinical coders that many diagnoses on our discharge letters were “uncodable” due to inappropriate coding nomenclature used, hence according to WHO ICD-10 rules, many cases had been incorrectly coded resulting in inaccurate HRG financial tariffs. Accurate discharge diagnoses have significant implications on patient management from a clinical governance point of view and in ensuring good continuity of patient care between services. Accurate clinical coding also contributes to appropriate data collection and analysis in audit and research. Assessment of problem and analysis of its causes An audit was conducted in August 2014 to assess accuracy of discharge letter diagnosis and co-morbidities in the paediatric department and relationship to ICD-10 coding nomenclature. To consider information governance implications of incorrect discharge documentation. We did a retrospective review of 50 discharge letters randomly selected from 7 paediatric wards in August 2014. Analysis 13 of 50 discharge letters (26%) had uncodable diagnosis. 6 of 50 case notes (12%) had co-morbidities that were not included on discharge letters. We analysed seven case notes’ discharge diagnosis (7/13) in detail and estimated an income loss of £1,359. Intervention A presentation was delivered in the Paediatrics departmental audit meeting to consultants and paediatric junior doctors to increase awareness of the negative financial impact and in compromising patient safety with poor information governance. Education on the role of a doctor in clinical coding was provided to all new paediatric junior doctors during rotation changeover induction. Study Design A re-audit was conducted using the same methods in October 2015. Strategy for change A Do’s and Don’ts table and common medical condition tariff table was designed to remind doctors of appropriate codable nomenclature when writing discharge summaries. Both tables were circulated via emails regularly over the past 12 months, and made available as posters on the wards. 2 lectures were given to graduating final year medical student in June 2015 to introduce clinical coding nomenclature. Full co-operation from consultants emphasising on accurate discharge diagnoses. Timeline: 12 months. Measurement of improvement (see Figure 1) Re-audit: Retrospective review of 78 discharge letters randomly selected from paediatric wards in October–November 2015. Effects of changes (See Figure 1) Education over 12 months showed a significant improvement (17%) in accurate/codable discharge diagnosis (91% vs 74%). 97% had codable nomenclature used in ward round documentation led by senior registrars/consultants (no quantitative comparison from last year). 4% improvement in accuracy of co-morbidities recorded (92% vs 88%). We estimated a significant gross financial savings and a definite improvement in the quality of our discharge summaries. Lessons learnt Senior paediatricians using codable nomenclature in wardround entries enables accurate/codable discharge letter writing by juniors. The word “suspected” was used most in NAI cases. This is appropriate but unfortunately not codable. Co-morbidities needs to be consistently recorded and available in admission clerking. Multifactorial elements contributes to financial outcomes (e.g. HRG codes/PBR/Snomed) Introduction to clinical coding should start from medical school. Message for others Accurate discharge letter ensures we maintain high standards of information governance, good continuity of patient care and safety, and accurate funding to the department.