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Related Experiment Videos

Increasing the accuracy of operative coding.

J Arthur1, R Nair

  • 1Department of Surgery, Macclesfield District General Hospital, Macclesfield, UK. jdrarthur@hotmail.com

Annals of the Royal College of Surgeons of England
|May 14, 2004
PubMed
Summary
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Coding clerks achieve higher accuracy in operative procedure coding than surgeons. Typed operative notes, especially with templates, result in more complete codes than handwritten notes, suggesting clerks are better coders.

Area of Science:

  • Medical Informatics
  • Clinical Auditing
  • Surgical Procedures

Background:

  • Operative codes are crucial for clinical audit and research.
  • Coding accuracy relies on legible and complete operative notes.
  • Coding is performed by either clerks or surgeons.

Purpose of the Study:

  • To assess the impact of handwritten versus typed operative notes on coding accuracy.
  • To determine if surgeons are more effective coders than coding clerks.

Main Methods:

  • 200 surgical procedures were prospectively randomized into handwritten (HN) and template-based typed (TN) notes.
  • Each procedure was coded by both the operating surgeon and a coding clerk.
  • Codes were compared for completeness, errors, and accuracy.

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Main Results:

  • Coding clerks achieved higher complete coding rates (97% for TN, 85% for HN) than surgeons (48% for TN, 62% for HN).
  • Handwritten notes resulted in more incomplete codes (15% for clerks, 62% for surgeons) compared to typed notes (6% for clerks, 53% for surgeons).
  • No coding errors were observed in either group.

Conclusions:

  • Typed operative notes, particularly with template-based fields, improve coding completeness and accuracy.
  • Coding clerks demonstrate superior coding performance compared to surgeons.
  • Procedure coding should be managed by trained coding clerks, especially when clinicians lack formal coding training.