Health Sciences, Prince Sultan Military College of Health Sciences, Dammam, 0000, Saudi Arabia.
F1000Res. 2024 Jul 22;13:820. doi: 10.12688/f1000research.149154.1. eCollection 2024.
Coding in medical procedures is crucial for patients, and errors made by hospital administration during the coding process can have an impact on both the financial results and the course of therapy. The present study aims to assess the accuracy of diagnostic and procedural codes as recorded by the hospital's coders and to also evaluate their impact on the hospital's revenue.
In a local hospital in Najran, Saudi Arabia, a cross-sectional observational analysis was conducted on patients with a clinical coder. The percentage of precision and error following the re-coding of cases was calculated using a statistical analysis.
Primary diagnosis was incorrectly coded in 57 (26 per cent) records, and secondary diagnosis was incorrectly coded in 21 (9.9 per cent) records. Inaccurate medical labelling has been seen in emergency rooms, operating rooms, and gynaecology facilities.
The percentage of records with the most incorrect coding was found to be 16 (7.5 per cent) in the emergency room, 10 (4.7 per cent) in the surgical clinic, and 5 (2.3 per cent) in the gynaecology/OBS clinic. Six (2.8 per cent) records in the private clinic had inaccurate secondary diagnoses, followed by four (1.9 per cent) and two (1 per cent) records in nephrology.
The percentage of inaccurate clinical codes in primary diagnoses reached (26.8 per cent) and the percentage of incorrect clinical codes in secondary diagnoses reached (9.9 per cent).
医疗程序编码对患者至关重要，医院管理部门在编码过程中出现的错误会对财务结果和治疗过程产生影响。本研究旨在评估医院编码员记录的诊断和程序代码的准确性，并评估其对医院收入的影响。
在沙特阿拉伯纳季兰的一家当地医院，对具有临床编码员的患者进行了横断面观察性分析。使用统计分析计算了重新编码病例后的精度和错误百分比。
主要诊断有 57 份（26%）记录编码错误，次要诊断有 21 份（9.9%）记录编码错误。急诊室、手术室和妇产科出现了不准确的医疗标签。
记录中编码错误最多的百分比为急诊室 16 份（7.5%），外科诊所 10 份（4.7%），妇产科/产科诊所 5 份（2.3%）。私人诊所的 6 份（2.8%）记录有不准确的次要诊断，随后是肾病学的 4 份（1.9%）和 2 份（1%）记录。
主要诊断的不准确临床编码百分比达到（26.8%），次要诊断的不准确临床编码百分比达到（9.9%）。
