The quality of national data on injuries requiring hospitalisation (Letter to the Editor)

Not availabl

The quality of cause-of-injury data: Where hospital records fall down

Objectives: This research identifies the level of specificity of cause-of-injury\ud morbidity data in Australia. The research explores reasons for poor-quality data\ud across different causes-of-injury areas, including a lack of clinical documentation\ud and insufficient detail in the classification system.\ud Methods: The 2002/03 hospital morbidity dataset of 593,079 injury-related hospital\ud admissions was analysed to examine the specificity of coded external cause-of-injury\ud data. \ud Results: While overall specificity appeared high, the cause of 47,660 injuries was not\ud specifically defined according to the code assigned. Only 56% of cases for whom\ud injury was the result of an accidental fall were assigned a specific code to identify\ud the causal detail; 19% were assigned an ‘Other Specified’ fall code, suggesting a\ud lack of specific code availability; and 25% were assigned an ‘Unspecified Fall’ code,\ud suggesting a lack of clinical documentation to facilitate code selection.\ud Conclusions: To improve the quality of injury-related hospital morbidity data, two\ud main areas to focus resources are: 1) the development of more specific cause-ofinjury\ud codes; and 2) the provision of more detailed documentation from clinicians.\ud Implications: Clinicians and clinical coders need to work together to improve\ud the quality of injury-related coded data through the provision of specific codes and\ud improved clinical documentation. Accurate and comprehensive data pertaining to the\ud circumstances surrounding hospitalised injury events will benefit injury prevention\ud and surveillance initiatives, provide justification for resources related to injury\ud hospitalisation, and assist in external cause research in Australia

Coding external causes of injuries: problems and solutions

Complete and accurate information about hospitalised injuries is essential for injury risk and outcome research, though the accuracy and reliability\ud of hospital data for injury surveillance are often questioned. To ascertain clinical coders' views of the reasons for a lack of specificity in external\ud cause code usage and ways to improve external cause coding, a nationwide survey of coders was conducted in Australia in 2006. Four hundred\ud and two coders participated in the questionnaire. The results of this study show that discharge summaries and doctors’ notes were the poorest\ud source of information regarding external causes, place of injury occurrence, and activity at the time of injury. Coders viewed missing external cause\ud information and missing documentation as having the greatest impact on the quality of external cause coding. A large majority of coders suggested\ud that improving clinical documentation in the emergency department and introducing a centralised structured form for external cause information\ud would improve the quality of external cause coding. Clinical coders are a valuable source of information regarding problems with, and solutions to\ud the collection of high quality data and this research has highlighted several areas where improvements can be made and further research is needed