Coding Matters video series: Minor changes to clinical documentation produce major benefits

Royal Adelaide Hospital (RAH) doctors have launched a series of educational videos to help clinical staff improve their documentation and coding, reaping major benefits for funding, research and clinical performance.

Minor improvements in the written language of medical records can lead to tens of thousands of dollars in funding, massive improvements in research efficiency, and enable accurate comparisons of clinical performance.

Coding matters

The Coding Matters video series, led and presented by RAH Hematology Registrar Dr Andrew Vanlint, provides specific practical advice on how clinical staff can make minor improvements to their documentation to achieve major benefits for them and the hospital.

Clinical codes are used to determine funding the doctor and hospital receives for the services they provide and are assigned based on the written documentation by clinical staff.

However, unclear or incorrect notes can result in miscoding or under coding which can drastically limit funding.

“If we’re doing the treatments, the money is spent, but we’re not actually getting the money back if we’re not coding correctly,” says Dr Vanlint.

Small improvements such as being more explicit, specific, or clear can have major benefits to the bottom line without causing much more work.

“We’re talking about an extra ten seconds, for an extra ten thousand dollars,” says Dr Vanlint.

Receiving the proper funding for the services provided is critical for hospital management to ensure adequate staffing, better training and education, better quality equipment and facilities and appropriately plan for future resource needs.

While receiving the correct funding is a powerful and easily measurable example, the benefits also extend to clinical auditing and research as well as assessing clinical performance.

“If you haven’t documented correctly in the first place, auditing becomes so much more difficult than it needs to be,’ says Dr Vanlint.

Proper documentation can drastically improve the efficiency of clinical auditing and clinical research, enabling auditors to rapidly locate the data they need, rather than manually wading through clinical notes.

Accurate coding also allows clinical staff and hospital management to make valid comparisons on clinical performance. This means health networks can demonstrate the high-quality care they provide and identify where they can make improvements.

Too good not to share

The video series is freely available online and has attracted interest from other health networks in Australia.

“It’s so simple and helpful, so we’ve made it publicly available so that other networks around Australia can benefit,” said Dr Vanlint.

“It’s too good not to share.”

Follow this link to access the Coding Matters series, including summary posters for each video.