Clinical documentation integrity: Its role in health data integrity, patient safety and quality outcomes and its impact on clinical coding and health information management
Author:
Affiliation:
1. La Trobe University, Australia
2. Shepheard Health Management Consultants, Australia
Publisher
SAGE Publications
Subject
Health Policy,Leadership and Management
Link
http://journals.sagepub.com/doi/pdf/10.1177/18333583231218029
Reference32 articles.
1. Health records as the basis of clinical coding: Is the quality adequate? A qualitative study of medical coders’ perceptions
2. Australian Commission on Safety and Quality in Healthcare (2023) Documenting information (Communicating for safety resource portal). Sydney, NSW: Commonwealth of Australia. https://c4sportal.safetyandquality.gov.au/documenting-information#:~:text=Clinical%20documentation%20is%20information%20that,or%20a%20mix%20of%20both
3. Computer-assisted clinical coding: A narrative review of the literature on its benefits, limitations, implementation and impact on clinical coding professionals
4. The diagnostic certainty levels of junior clinicians: A retrospective cohort study
5. A qualitative evaluation of clinically coded data quality from health information manager perspectives
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