Spotlight on: our Clinical Coders

Our team of Clinical Coders record information about every patient who visits our hospital, investigating all aspects of their journey from start to finish.

Over 30 people make up our Coding Department as they are responsible for accurately recording the stay of each patient, both inpatients and day cases, who have been discharged each month.

This information is entered into the hospital PAS system. At present we are coding the data of around 16,500 patients a month.

“There’s a detective element to this job,” said Petrina Eve, Deputy Clinical Coding Manager.

“We are clinically led by information on the discharge letter and have access to the case notes and multiple electronic clinical systems to piece together a clear picture of all relevant diagnoses and procedures performed during patient admission.

“Our role is to translate this information into alphanumerical codes using diagnostic and procedural classifications. We have rules, conventions and standards to adhere to and this ensures the uniformity of data for consistency and comparison across NHS trusts.

“There are thousands of codes available and we strive to record the information to the highest level of specificity.”

All coding departments across the country follow the same rules. The data is used to underpin the payment system and is of wider importance due to its use in the planning, delivery and monitoring of healthcare services.

“For all these reasons it is important we’re as accurate as possible,” said Rosemary Hardy-Shepherd, Clinical Coding Divisional Lead.

“Sometimes the clinical notes are handwritten and we need to spend time deciphering these and contacting the clinicians for clarification to get a clear picture of the patient’s journey through the hospital.”

Our Clinical Coding team has been recently praised for the ongoing work they are carrying out alongside our NICU team to improve the accuracy of documentation used by the coders when recording the data for neonates.

This is an important clinical engagement piece to ensure our Coding team have what is required in the discharge summary to guarantee the most accurate and complete record of babies’ care in hospital.

“This is the first time we have been able to have this level of engagement and we hope to work in a similar way with other teams around the hospital,” said Petrina

A Consultant Liaison team have been working with the Coding team for over a year to help bridge the gap between coders and the clinical world of the Trust.

This has helped to raise the importance of the completion of discharge letters, accurate recording of information in case notes and validating coded records to include deceased patients.

“We also organise awareness sessions with clinicians and medics to share the importance of recording accurate information,” added Rosemary.

“Sometimes we come across a diagnosis that we have never seen before – this was the case with Covid-19.

“Covid-19 needed to be accurately coded to allow analysis and tracking of cases of the disease. The classification used by our department is issued by the World Health Organisation (WHO). There is a chapter of codes for ‘emergency use’ and it was from there codes were assigned to accurately represent the new disease. We had to learn on the spot how to handle a vast amount of new information.”

“To become a Clinical Coder it is not necessary to have a clinical background, but having worked in a healthcare setting and knowing how the human body works definitely helps,” added Petrina.

“If you are interested in medical information and clinical procedures, but not so keen on working in a clinical environment, are curious and have great attention to detail, then you may want to consider a position with a Coding team.”

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