A survey on hospital patients coding accuracy in Ahvaz, Iran.

ABSTRACT

Background: The diagnosis coding and medical procedure are methods of treatment that helps patients to organize and classify information correctly. Coding is a related factor with the quality to provide the data of illnesses and injuries. Aim: To examine rate of the coding accuracy of hospital patients of Imam Khomeini in Ahvaz (Iran) during spring 2010. Material and methods: In this cross-sectional study that was performed in 2010, society of investigation was 5062 records of patients admitted to the surgical ward of Imam Khomeini Hospital in Ahvaz from which 260 records were selected incidentally and orderly. Instrument of data collection was a checklist developed by the researchers based on library resources and the accuracy was confirmed in the narrative checklist used by expert faculty in this. After the data were collected, they analyzed using Excel software. Results: The most accurate coding was related to other procedures (92.61%) and least accurate coding was related to the major diagnosis (84.91%) and the lowest completeness of the encoding was related to other diagnosis regarding 66.88%. Conclusion: The results showed that the accuracy of diagnosis coding and procedure was optimal, but the level of completeness of diagnosis coding was too low regarding to hospital training.