Factors Affecting Clinical Coding Errors

Abstract

Background: Coding errors lead to incorrect classification of diseases and thus severely affect health care planning and epidemiological research. Objectives: This study aimed to investigate the factors affecting clinical coding errors. Methods: This descriptive study was conducted in 2020 in 2 stages. In the first stage, a questionnaire was developed by examining relevant resources, documents, and articles. The questionnaire’s validity was examined by 5 health information management experts. Its reliability was determined using Cronbach α and correlation coefficient (r = 0.84%). In the second stage, the data were collected by visiting teaching hospitals affiliated with Shahid Beheshti University of Medical Sciences, examining the medical records, and interviewing the coders. Data were analyzed using descriptive statistics. Results: Non-observance of diagnostic principles by physicians, illegibility of medical records, use of ambiguous and nonstandard abbreviations, and incomplete medical documentation were the most important causes of coding errors. Conclusions: Considering the importance of coding in presenting correct data as a powerful lever in health care, knowledge of the factors affecting the occurrence of coding errors will greatly contribute to the selection of effective strategies to reduce and eliminate errors.