J Arthur1, R Nair. 1. Department of Surgery, Macclesfield District General Hospital, Macclesfield, UK. jdrarthur@hotmail.com
Abstract
INTRODUCTION: Operative codes provide a readily retrievable record of operative procedures and interventions and are invaluable in performance of clinical audit and research. In most hospitals, coding is performed by coding clerks who depend on legible complete operative notes for coding. In others, coding is by the operator/surgeon. The aim of this audit was to determine the impact of hand-written and typed operative notes on accuracy of coding as well as deciding if the operator is the better coder. METHODS:A total of 200 operations/procedures performed by one surgical firm were randomised, prospectively, into hand-written (HN, 100) and template-based typed (TN, 100) operation notes. Each procedure was coded by the operator/surgeon as well as by the coding clerk. The results were compared for error, incomplete and complete codes. RESULTS: Coding clerks were found to be better coders with 97% of TN and 85% of HN coded completely compared to 48% and 62%, respectively, by operators. There were more incomplete codes for HN compared to TN (15% versus 6% for coders and 62% versus 53% for operators). There were no error codes for both groups. CONCLUSIONS: These results suggest that the quality of coded information is poorer if operation notes are hand-written rather than typed, with template-based mandatory fields in typed notes possibly acting as an aide-memoir in generating complete, accurate notes. In the absence of formal training for clinicians, coding of procedures should probably be left to coding clerks.
RCT Entities:
INTRODUCTION: Operative codes provide a readily retrievable record of operative procedures and interventions and are invaluable in performance of clinical audit and research. In most hospitals, coding is performed by coding clerks who depend on legible complete operative notes for coding. In others, coding is by the operator/surgeon. The aim of this audit was to determine the impact of hand-written and typed operative notes on accuracy of coding as well as deciding if the operator is the better coder. METHODS: A total of 200 operations/procedures performed by one surgical firm were randomised, prospectively, into hand-written (HN, 100) and template-based typed (TN, 100) operation notes. Each procedure was coded by the operator/surgeon as well as by the coding clerk. The results were compared for error, incomplete and complete codes. RESULTS: Coding clerks were found to be better coders with 97% of TN and 85% of HN coded completely compared to 48% and 62%, respectively, by operators. There were more incomplete codes for HN compared to TN (15% versus 6% for coders and 62% versus 53% for operators). There were no error codes for both groups. CONCLUSIONS: These results suggest that the quality of coded information is poorer if operation notes are hand-written rather than typed, with template-based mandatory fields in typed notes possibly acting as an aide-memoir in generating complete, accurate notes. In the absence of formal training for clinicians, coding of procedures should probably be left to coding clerks.