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A large retrospective recoding study of 4000 records was conducted in a group comprising three large Sydney teaching hospitals. The aim of the study was to identify the specific errors and problems relating to medical record documentation and coding. This paper describes in detail the sampling, methodology and analysis of results. The study revealed an error rate of 47% (all diagnoses and procedures were included) and a change in DRG assignment of 9.25%. Inconsistent/unclear documentation accounted for the greatest percentage of the errors. In 63.3% of the cases the change in DRG assignment following correction of errors was favourable financially for the hospitals. The conclusion drawn is that ensuring consistency in coding practices and policies is one of the major issues facing the medical record profession.
Mary Donoghue (Tue,) studied this question.
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