Background Accurate and legible documentation is essential; not only for safe patient care, but also for aiding the coding department to accurately code the clinical episode. After an episode, hospital clinical coders go through documentation on medical notes to assign ICD-10 (International Statistical Classification of Diseases and Related Health Problems) codes which then are grouped together to generate a HRG code (Healthcare Resource Group code). This HRG code defines payment. Inaccurate coding can lead to a variation in assigned codes and therefore affect the payment received for the episode.

We compared the cost attributed to an inpatient episode between: Diagnosis and intervention codes assigned by clinical coders on original documentation with episodes recoded by medical staff adding in missing information on the clinical episode.

Methods A random sample of 40 notes was selected over 4 weeks from the general paediatric ward. Information on the clinical episode was then gathered from patient notes, pathology system, discharge summaries and imaging database by two researchers who were members of the medical staff. The cost calculated by the researchers was then compared to that attributed when the same episode was previously coded by the clinical coding department. Results were analysed jointly working with clinical coders and finance managers.

Results The cost attributed for the 40 clinical episodes by the coding department was £41,676 compared with £42,151 when coded by the medical team. This equates to a difference of £475 (1.1%) over 40 sets of notes. With the admission of around 150 patients a month, this extrapolates to an additional £2000 a month. This could fund an extra nurse.

Discussion Legible and accurate record keeping leads to improved communication between team members and enhances patient safety. It also enables better real time trackers of conditions and trends in activity.

This QIP also demonstrates that the quality of documentation has financial implications with improvement in notes, potentially leading to more accurate coding thereby ensuring the department receives the appropriate reimbursement for every patient episode.

We developed a coding proforma to aid the medical team in improving documentation and assist the coding department to accurately code the clinical episode.