A Comparison of Coding Quality for Burn Injuries in Deceased and Non-Deceased Patient's Records

Because of increasing incidence of burn injuries، prevention programs become more important. Accurate information is the essential requirement for implementation of such programs which obtained based on correct and high quality coding. In this research، coding quality for burn injuries in deceased and non-deceased patients'' records in Tabriz Sina Hospital were studied and compared.

This was a cross-sectional comparative study. Research population was included 1500 medical records of hospitalized burned patients in Sina hospital، Tabriz in 2010-2011. The sample size based on pilot study was determined 75 cases from each groups and was performed using systematic random sampling. Data were collected using a data extraction form that content validity was confirmed by panel of experts. SPSS software version 16 has been used for data analysis and descriptive and inferential statistics such as frequency، percentage، mean، SD and Mann-Whitney test were applied.

The accuracy of 41. 8% and completeness of 61. 4% were obtained from the deceased patients’ record while it was 47. 3% and 71. 2% for the non deceased patients respectively. The fifth character were not been coded in neither deceased nor non-deceased group. Timelines was average 50 day that there was great distance with standard of WHO (2 days).

To improve the coding quality in the deceased patients، coding of other diagnosis and activity should be considered by coders. Accordingly some attraction، punishments، or relative regulations should be defined for coders to attract them to do their best and on time coding in line with entrance of codes into Hospital Information System.