Incomplete documentation, unavailability of materials and resources to assist the coding process and lack of clarity in the records were some of the problems encountered by a team of researchers from the Faculty of Medicine of the University of Porto (FMUP) and from CINTESIS – Center for Health Technology and Services Research, which alerts to the lack of quality of data in health records.
“The lack of quality of clinical data may compromise the communication between health professionals and the correct assessment of the patient diagnosis,” explains Vera Pires, principal investigator of the study, recalling that “the data collection and storage is essential for future treatment of patients”.
Clinical coding is the process of transforming information contained in health records about diseases into numeric or alphanumeric codes. Health records represent a source of data on the status of the patient’s health, disease, disease progression, among others. They have the function of helping health professionals in the provision of care, constituting clinical and legal support.
According to researchers, clinicians are little aware of the importance of these records in a coding activity. This study, published in the scientific journal Health Information Management Journal, raises some questions about the incomplete documentation which can hinder the coding process.
“In fact, the existence of errors in the coding process, such as the absence of discharge notices and operative reports, do not allow correct assessment of patient diagnosis”, explains Alberto Freitas, coordinator of the study, FMUP professor and CINTESIS investigator.
In this study, the researchers also present a set of solutions to improve the quality of health records. To use more concise standards and promote external audits, are just some of the measures pointed out for the improvement of coding activity and care provision. On the other hand, the team of researchers states that there should be greater awareness on the part of health professionals about the importance of these records.