Clinical documentation requirements for the accurate coding of hospital-acquired urinary tract infections in Australia

Abstract

Aims We evaluated the accuracy of medical coders in distinguishing the aetiology of urinary tract infection according to clinical documentation. Methods The clinical documentation of patients coded as having had a hospital-acquired urinary tract infection from January to June 2020 at two Melbourne hospitals were assessed for community or hospital acquisition. Results We found that 48.89% of cases were inaccurately categorised as hospital-acquired, due to insufficient detail in clinical documentation. Risk factors for hospital-acquired urinary tract infection were present in at least 30% of correctly categorised cases. Conclusions Clinical documentation is not filled out with sufficient detail or in a timely enough manner for clinical coders to distinguish between hospital or community origin.