The Audit Commission has reviewed 50,000 records and found that close to 1 in 5 records were wrongly coded: Audit Commission - PbR Data Assurance Framework 2007/08:
The most common issue which affected the accuracy of clinical coding was the quality of the source documentation from which the coding data was abstracted. This included clinical coders working from discharge summaries rather than full case notes, illegible or poorly structured case notes, lack of access to additional information systems by coders and insufficient information included on electronic patient records. If coding accuracy is to improve, then trusts must improve the standards of source documentation. Other problems included the adequacy of trust coding arrangements and the level of clinician involvement and validation. In particular, the audits demonstrated that training and development of coders had more of an impact on limiting the number errors than the number of coding staff. Lack of clarity in national guidance on identifying and coding co-morbidities and data definitions also contributed to error rates. However, in the case of data definitions, this was not found to be as significant an issue as when we raised it following our pilot reviews in 2006.
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