DR RACHEL DARBY, DR NICK KENNEDY and SUE EVE-JONES highlight the importance of accurate clinical coding and clear recording of clinical events in case notes.
Critical Care (CC) is one of a hospital’s most expensive clinical departments. The introduction of a UK national tariff for CC has focused the attention of managers, clinicians and commissioners to better understand the costs of providing CC. Accurately coding all activity is vital for hospitals to understand their activity and costs, as well as to improve data quality.
At the Taunton and Somerset NHS Trust, the hospital’s CC unit and clinical coding department collaborated on the audit of the clinical coding of intensive care unit events. The aim was to improve the overall accuracy of coding by investigating areas where coder error could be reduced.
In contrast with traditional clinical coding audit, which takes place within the clinical coding department, close collaboration between the lead clinician for CC and the manager of the clinical coding department was established from the start, with regular discussions and feedback at each stage of the project.
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