QuaLITyCODING, maINTaINING OF THE surGEryFILE, aND QuaLITy OF CarE IN surGEry

Abstract

The purpose of this study was to optimize the code recording, and thus the valuation of the diagnoses called “Associated Complications and Morbidities” by the departments of surgery of the hospital of Alençon Mamers. We also were able to estimate the quality of the contents found in the patient file. Was studied the coding of acts and diagnoses, found in the “Résumé d’Unité Médicale” (RUM) (the encoded summary of a medical unit stay) if the stay had been in only one surgery unit. The stay occurred during two periods of three months. The economic output, the percent of coding changes, the review of the coding sources’ dispatching, the quality to the file’s maintaining and the presence of legal papers were analyzed. The increase of the output was about 110 000 € over the two periods of study and the percentage of modified summary of 65 %. The number of Associated Significant Diagnoses (DAS) coded by the surgeons increased between the 2 periods. The changes were mainly an increase of the level of severity. The surgical write-ups were listed over 95 % of the studied medical charts, and the stay’s reports over 55 %. The high rate of coding changes indicates the inconvenient appropriation of the coding rules. The most corrected coding were the “DAS”. The added ones were mostly about post-surgical complications and patient’s medical background. The most used information sources were the anaesthesia’s and the nursing’s files. Our study improved the coding, and the output. We also elicited the inadequate fulfilment of the medical record. The main suggestion was to recruit a medical doctor, dedicated to the coding of the stays of the patients in surgery and to the filing of those patients’ health records.