Regarding thr piece in HSJ by Tim Kelsey of Dr Foster Intelligence: 'Clinical record taking has been left to coders for too long.' Excuse me? Clinical information is recorded by clinicians. Coders then translate this information into clinical codes in accordance with National Standards.
'NHS clinical coders are relatively poorly paid.' No-one could dispute that. In central London coders have been assimilated on AfC Band 4, but outside the capital trusts are attempting to attract trainee coders to Band 2 posts.
Nevertheless, many of us are graduates. All of us have completed a foundation clinical coding course and are required to attend specialist clinical coding workshops and refresher courses every two years.
Many of us have achieved, or are working towards, the National Clinical Coding Qualification (pass mark 90%). So, your readers can be assured that it is OK to leave coding to coders - we do know what to do and how to do it.
'Some organisations are now placing coders alongside clinicians on ward rounds. In this way the coder can verify information from both the clinician and the patient at the bedside. Data quality and confidence in that data therefore improves.'
Can this be true? Coding accuracy can only be assessed by accredited clinical coding auditors, comparing codes allocated by coders with codes allocated by auditors, using the clinical information recorded by clinicians as the source document.
The quality of coded data undoubtedly improves with clinical engagement in the coding process, but this is a consequence of the clinicians understanding the need to document operations, treatments and diagnoses fully - and not due to coders attending ward rounds and verifying information from the patient at the bedside. This is not good practice, Dr Foster, and it is irresponsible to recommend it.
Anna Turner,Clinical Coder, St Mary's trust