Codage PMSI optimisé grâce aux transmissions infirmières

Abstract

introduction: Medical coding is an increasingly strategic function in hospitals. It is continuously
being improved through various data sources. In 2013, an optimization tool based on
nurses’ notes was implemented at the Montpellier teaching hospital. The aim of the study was
to assess the impact of this tool on relevant diagnosis codes and on revenue.
methods: Automated alerts are generated from key words present in nurses’ notes. Then discharge
coding is checked and improved by the DIM accordingly.
results: Out of 13,977 discharge records checked by the DIM in 2013, two thirds had one
alert or more and 1,480 of them (16.2%) were improved in terms of coding. The incidence of
specific diagnostic codes increased by 50% as compared to 2012. The average income gain was
equal to 1,122 Euros by stay.
conclusion: Using nurses’ notes to improve medical coding is a promising way. It might
contribute to add value to nursing care. However, its generalization is dependent on the evolution
of electronic medical record in hospitals.