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ORIGINAL ARTICLE
Year : 2013  |  Volume : 1  |  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


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

Correspondence Address:
Asghar Ehteshami
Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan
Iran
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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


DOI: 10.4103/2347-9019.128118

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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.


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