|Year : 2013 | Volume
| Issue : 2 | Page : 78-84
Study of complying with principles of burn diagnosis recording and coding in Imam Musa Kazim hospital according to the ICD-10 instructions
Sakineh Saghaeiannejad1, Asghar Ehteshami2, Mahtab Kasaei3, Sedigheh Shokrani3
1 Social Determinants Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
2 Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Health Information Technology, School of Health Management and Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
|Date of Web Publication||4-Mar-2014|
Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan
Source of Support: This study was part of a research project supported by Information Technology Research Center for Health Sciences at Isfahan University of Medical Sciences (grant No: 292032), Conflict of Interest: None
Introduction: Coding of disease makes it possible to recover data in the medical records for a diversity of medical, managerial, financial and research objectives. The correct coding of disease and medical interventions greatly helps to effective planning for prevention of injuries, especially burns. Therefore, in this study we aimed to determine the extent of complying with the principles of diagnosis recording and coding of inpatient burn cases in Imam Musa Kazim Hospital. Materials and Methods: This is an applied study with a cross-sectional descriptive method in which sampling was done from skin burn cases from October 2010 to September 2011 in Imam Musa Kazim Hospital using Morgan table, and 300 cases were studied. A researcher made questionnaire was used to collect data made up of two sub-questionnaires to evaluate the principles of diagnosis recording (with 21 components), and to evaluate the accuracy of diagnostic codes (with 15 components), respectively. Reliability and validity of questionnaires were confirmed by professors of the Department of Health Management and Information Technology at Isfahan University of Medical Sciences. The researchers studied 300 cases, and analysed obtained data using descriptive statistics (indices of central tendency and dispersion) and the Pearson correlation co-efficient and SPSS software version 20. Results: Findings showed that the overall compliance of the principles of burn diagnosis recordings is 78.27%, and the overall accuracy of codes assigned to burn diagnosis and related measures is 74.17%. No significant relation was observed between these two variables (r = −0.024, sig = −0.673). Conclusion: The principles of diagnosis recording and the burn coding are well complied. However, since there is no significant relation between the overall compliance of the principles of burn diagnoses and the accuracy of related coding, an improvement in the documentation of burn diagnoses and coding requires empowerment of both physicians and coding staff.
Keywords: Burns, diagnosis, disease coding, documentation, International Classification of Diseases-10, measures
|How to cite this article:|
Saghaeiannejad S, Ehteshami A, Kasaei M, Shokrani S. Study of complying with principles of burn diagnosis recording and coding in Imam Musa Kazim hospital according to the ICD-10 instructions. Int J Health Syst Disaster Manage 2013;1:78-84
|How to cite this URL:|
Saghaeiannejad S, Ehteshami A, Kasaei M, Shokrani S. Study of complying with principles of burn diagnosis recording and coding in Imam Musa Kazim hospital according to the ICD-10 instructions. Int J Health Syst Disaster Manage [serial online] 2013 [cited 2022 Jan 25];1:78-84. Available from: https://www.ijhsdm.org/text.asp?2013/1/2/78/128118
| Introduction|| |
Skin burn is an injury or illness associated with long-term complications such as disability, and a major cause of death, noteworthy from aspects of economic and financial pressure it puts on the patients and the healthcare system. , At least two-thirds of all fatal accidents such as burns occur in developing countries such as Iran. The number of deaths in elderly people is more. ,
According to the national report of the Disease Control Center of the Ministry of Health and Medical Education, burns with 56,364 cases in 2006, represent about 5% of all accidents in the country and are considered as of the major causes of injuries.  In the USA, 1,100,000 burn cases occur annually of which 4% are admitted in specialised burn centres and 10% die. 
Clinical experiences of survivors of burn injuries indicate the impacts on all aspects of life associated with permanent physical and mental changes.  The adverse consequences resulting from fire is more severe than from other cases.  90.2% of burns are of heat type (boiling water as the major cause), 7.5% are caused by electricity, and 2.3% are caused by chemicals. 
Accurate information about burn cases is a base for planning and effective measures to prevent burn injuries.  Injury prevention requires accessibility of the exact statistics, which is only achievable through an exact coding system and enforcement of related rules.  Factors such as incomplete data records, doctors' lack of familiarity with the principles of correct coding and disease classification systems, and carelessness and inexperience of coders are the main causes of incorrect data coding. 
Application of coding principles and not using abbreviations significantly reduces coding errors.  Failure to comply with coding rules results in the lack of quality of classification and injuries prevention, burns and lack of an accurate estimate of the extent of the burn, which itself can make it difficult to compare data with other systems and planning at local, national and international levels. 
Healthcare data indicate that the provided healthcare, justification of services and costs, is a base to assess the quality of care provided to the patient. The survival of any healthcare institution depends on the correct coding of data. It is because collecting accurate data and appropriate classification has a significant impact on the efficiency and effectiveness of the decision-making process. ,
The amount of incorrect coding of diseases is 30% and 16% in UK and Saudi Arabia, respectively.  In our country, due to coders' failure to understand the importance of coding of burn injuries, coding guidelines are not properly implemented.  Average failure to comply with the instructions for burns coding in Medical Universities of Shahid Beheshti and Iran are 41.7% and 44.2%, and the external causes are 47% and 47.9%, respectively.
Failure to comply with instructions, results to the decreased coding quality and rise of complications in correct refunds from insurer to the patients, which has its own legal problems in turn.  Given the above, and failures involved in registering and completing medical records and providing coded data, particularly for burn injuries, this study aimed to evaluate how the principles of diagnosis recordings and coding of burns cases are complied with in Imam Musa Kazim specialised centre.
| Materials and Methods|| |
This is an applied study with a cross-sectional descriptive method in which sampling was done from skin burn cases from October 2010-September 2011 in Imam Musa Kazim Hospital (1200 cases) using Morgan table and a confidence level of 95%, and 300 cases were studied. A researcher-made questionnaire was used to collect data, which was made up of two sub-questionnaires to evaluate the principles of diagnosis recording (21 components) and to evaluate the accuracy of diagnostic codes (15 components), respectively. Reliability and validity of questionnaires were confirmed by professors of the Department of Health Management and Information Technology at Isfahan University of Medical Sciences. Questions about severity, percent, position, external causes, infections and treatment measures were asked in the questionnaires. The researchers studied 300 cases and the analysed data were obtained using descriptive statistics (indices of central tendency and dispersion), Pearson correlation co-efficient and SPSS software version 20. Components with frequency of 0-50% were considered as undesirable, 51-80% as relatively good and 81-100% as desirable and acceptable.
| Results|| |
According to [Table 1], the doctors have appropriately reported the burn severity and percentage. However, the same report of degree burns severity is observed in only half of the documentations. Furthermore, the same report of burn is quite desirable in related forms. In addition, intentional or unintentional caused burn injuries and external causes of burns have received little attention in diagnosis by physicians. Physicians have done well in recording multiple burn positions and treatment measures when filling in the patients records.
|Table 1: Complying with principles of burn diagnosis recording in inpatient cases in Imam Musa Kazim hospital|
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The complying with principles of diagnosis in inpatient burns cases in Imam Musa Kazim Hospital is as follows: (i) burns severity: 77%, (ii) burns percent: 86%, (iii) infections caused by burns: 75%, (iv) external causes of burns: 58%, (v) multiple burn positions: 91%, (vi) single burn position with multiple degrees of burn: 66% and (vii) treatment measures: 99%.
[Table 2] shows that the accuracy of codes of the burns severity and percentage is desirable. In contrast, coding principles for burn infections, burns caused by self-harm or abused, intentionality or non-intentionality of burns, external causes of burns and treatment measures, were not acceptably compliance with. Coding of organs involved in multiple burn positions also need more attention.
|Table 2: Complying with coding principles of burns in inpatient cases in Imam Musa Kazim hospital|
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The complying with principles of burns coding in inpatient burns cases in Imam Musa Kazim Hospital is as follows: (i) burns severity: 84%, (ii) burns percent: 98%, (iii) infections caused by burns: 18%, (iv) external causes of burns: 37%, (v) multiple burn positions: 62%, (vi) single burn position with multiple degrees of burn: 99% and (vii) treatment measures: 33%.
According to [Table 3], there is no significant relation between overall complying with principles of burn diagnosis and overall complying with principles of burn diagnoses coding (r = −0.024, sig. = 0.673). Moreover, there is a weak significant relation between complying with principles of burn diagnosis with accuracy of related coding (r = 0.154, sig = 0.009) and between complying with principles of burn diagnoses coding with accuracy of related coding (r = 0.188, sig. = 0.001).
|Table 3: The relationship between complying with principles of burn diagnosis and complying with principles of burn diagnoses coding in inpatient cases in Imam Musa Kazim hospital|
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In contrast, there is no significant relationship between complying with principles of burn severity recording with accuracy of related coding (r = −0.069, sig. = 0.239), between complying with principles of burn infections recording with accuracy of related coding (r = −0.010, sig. = 0.869), between complying with principles of recording external causes of burns with accuracy of related coding (r = −0.283, sig. =0) and between complying with principles of burn positions recording with accuracy of related coding (r = −0.023, sig. = 0.694).
| Discussion|| |
Complying with principles of diagnosing burns severity was desirable, which is contrary to the results obtained in the Farzandipour studies. Based on his study, principles of recording burn severity were not desirably observed.  One reason for this inconsistency can be due to different reports of burns severity by physicians in relevant forms.
Physicians have desirably complied with principles of recording infections and the same reporting in relevant forms. In general, principles of recording burns percentage were desirably observed and are consistent with the results of the Farzandipour studies. According to him, principles of recording burns percentage were 100% complied with reference. 
Principles of recording infections associated with burns were moderately observed and 98% of these infections were reported in relevant forms. The overall compliance rate with principles of recording infections caused by burns was moderate. According to Faghri, 86% of burn patients have experienced infections during hospitalisation. Also, the Akhi study shows that 91% of deaths resulting from burns were culture-positive.  The importance of clinical detection of bacteria in burn wound infections and their resistance to antibiotics indicates the need to take appropriate measures to prevent and minimise the spread of infections in hospitalised patients. 
Principles of recording external causes of burns were moderately observed, which is consistent with the Farzandipour study. According to Farzandipour, the principles of recording diagnosis of external causes were 65% observed and the highest compliance rate was observed in principles of recording harm nature (100%), and the lowest compliance rate was observed in recording the location of the incident.  Also, in his study, Mashoufi concluded that the cause of the accident was recorded only with a rate of 8.5% in admission and discharge forms.  According to Bahrampour, the principles of recording external causes of burns were complied with a rate of 16.43%.  The results of the last two studies are inconsistent with the present study.
In this study, multiple burn positions and organs involved in multiple burn positions were completely documented by the physician. But only 79% of documents were reported as the same in relevant papers. The average compliance rate with principles of recording multiple burn positions was desirable, indicating the importance of mentioning the burn position by physician.
The compliance rate of recording burn positions by physicians was desirable, but same reports in relevant forms were moderately observed. In general, the overall compliance rate of principles of recording diagnosis of a single burn position with multiple burn levels was relatively good.
The compliance rate of recording treatment measures and the same report in relevant forms is quite desirable. In general, the overall rate of complying with principles of recording medical treatment measures was desirable, which is consistent with the results of Farzandipour, Farahabadi and Saif Rabi'ei. According to Farzandipour, principles of recording treatment measures were complied with a rate of 77%, and the highest compliance rate was related to recording the treatment nature or surgeries performed with a rate of 98.5%.  The mean percentage of recorded clinical data related to surgeries in relevant forms is 94.8%, according to Farahabadi.  Also, according to Saif Rabi'ei, 86% of the physicians documented the treatment measures or surgical procedures in relevant forms. 
According to Mashoufi, first surgical treatment and surgical treatment were recorded in relevant forms with a rate of 52% and 34%, respectively.  According to Sharifian, data of 45.4% of surgical treatments in the public hospitals and 32.8% of surgical treatments in specialty hospitals were not recorded, and the overall rate in all hospitals was 40.5%.  According to Bahrampour, the principles of recording treatment measures were complied with a rate of 47.1%.  These results do not support the results of present study, which can be due to the ignorance of physicians of documenting treatment measures.
In the present study, the accuracy of coding of severity of burns in inpatients was desirable, indicating the physicians' precision in accurately assigning the codes. However, it is recommended that physicians pay more attention in recording the burns severity in relevant forms.
The correct percentages of burn recorded, have resulted in the correct coding, indicating the sufficient attention physicians pay on this.
Coding accuracy for infections associated with burns is highly undesirable, and for infections resulting from burns is undesirable. In general, the rate of complying with principles of recording infections is undesirable, which might be due to coders' ignorance to infections and recording relevant codes.
Coding accuracy for external causes of burns is relatively desirable, and for intentional or unintentional nature of the burns and self-harmed burns or burns resulted from abuses is highly undesirable, but for burns resulted from treatment measures is quite desirable. In general, coding accuracy for external causes of burns is quite desirable, which is consistent with the results of the Hunt study.  Coders ignorance to intentional or unintentional nature of burns and not recording whether the burns are caused by self-harm or abuse is the main reason to decreased accuracy of coding of external causes of burns. In addition, doctors have not addressed the minor cases of external causes in the documentations, indicating a lack of knowledge of the importance and necessity of registration of these codes in patients' cases.
The results show that the coding accuracy for the burn positions is moderate, for multiple burn positions is desirable, for organs involved in multiple positions is undesirable, and for the main condition in multiple burn positions is desirable. In general, the overall compliance rate for coding accuracy of multiple burn positions is at average level, which can be due to not coding the organs involved.
Coding accuracy of single burn positions with multiple burn degrees is desirable.
Coding accuracy for treatment measures is undesirable, which is inconsistent with results obtained in the Navistky and Walravan studies. According to Navitsky, 67% of surgery documents were incomplete and residents had incorrectly coded in 4-28% of the cases.  Also, Walravan showed that the completeness rate of the same treatment measures was 5.4% and its accuracy rate was 70.3%.  The decreased accuracy rate of coding despite the high documented treatment measures can be due to coders' ignorance, and coders are advised to pay more attention to coding of treatment measures.
Generally, the rate of compliance with principles of recording burn diagnosis and principles of burn diagnosis coding is relatively desirable, which is consistent with the results of the Farzandipour and Bahrampour studies. According to Farzandipour, the compliance rate for principles of diagnosis recording is 87%  and according to Bahrampour, the compliance rate for principles of diagnosis coding is 58.8%.  The results obtained by Ahmadzadeh were more desirable than results obtained in the present study, likely demonstrating the attention physicians pay to filling in medical records. According to Ahmadzadeh, the completeness rate of physicians' orders was 100% and for primary diagnosis was 89.5%. In summary forms, highest completeness was for final diagnosis with a rate of 97.9%, which is quite desirable. 
According to Esmaili, the quality of registrations by residents and by interns was reported to be 83.3% and 66.4%, respectively.  Although the current study is about registrations made by physicians, but the results are consistent.
Researches carried in Iran indicate the desirable accuracy of coding. According to the study by Ahmadi, the validity of codes for original diagnosis and the main interventions in Shahid Beheshti University of Medical Sciences were 85.52% and 85.41%, in Tehran University of Medical Sciences, they were 79.23% and 80.62%, and in Iran University of Medical Sciences, they were 83.32% and 85.23%, respectively. The completeness rate of codes for original diagnosis and the main interventions in Shahid Beheshti University of Medical Sciences were 97.96% and 98.93%, in Tehran University of Medical Sciences, they were 96.91% and 94%, and in Iran University of Medical Sciences, they were 93.06% and 96.70%, respectively,  being consistent with the results obtained in the present study.
According to Walravan, the accuracy rate for valid diagnosis is 68.5%, for accuracy of diagnosis coding, it is 78.9%, and for its completeness, it is 63.9%.  In his study, Zun concluded that the completeness rate of data in emergency unit cases is 46-80%. 
According to Galil, the completeness rate for death certificates is 81%.  All these studies are consistent with the results of the current study.
Based on data from [Table 3], educating principles of diagnosis recording of severity, position, external causes and infections of burns are not enough to correct codes, and coders need to be trained as well. That is because there is no significant relationship between these variables. However, the significant relationship between complying with the principles of recording burns percentage and treatment interventions with accuracy of related coding indicates the influence training such principles has on improving the accuracy of related codes by physicians. Moreover, there is no significant relationship between overall compliance with principles of recording diagnosis and coding accuracy in burn cases. This means that to improve documentation of diagnosis and accuracy of coding, both physicians and coders need to be empowered.
| Conclusions|| |
Based on results obtained, the compliance rate of principles of recording diagnosis is more than compliance rate of coding accuracy. Inaccuracy of coding has consequences such as lack of appropriate planning for providing services, and providing incorrect statistics to researchers and managers. Given the importance of accurate coding and reporting and the effect they have on timely reporting in diagnosis of causes of disease, and planning for prevention and development of such accidents, it is necessary to improve the knowledge of physicians and coders in this regard. This study confirms the need to train employees, and that is why a system of reward and punishment seems necessary. Authors suggest that physicians of Imam Musa Kazim Hospital must be trained about registration of external causes of burns such as abuse caused burn cases, and intentional or unintentional nature of incidents, and the importance of recording such data in patients' medical records.
In selecting burn coding, codes such as codes of infections associated with burns, intentional or unintentional nature of the burns, self-harm or abuse caused burns, organs involved in multiple positions, and treatment measures undertaken need to be selected more accurately.
In total, there is no significant relation between overall compliance rate of principles of diagnosis and overall compliance rate of coding accuracy in burn cases, This means that to improve documentation of diagnosis and accuracy of coding, both physicians and coders need to be empowered.
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[Table 1], [Table 2], [Table 3]