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In the current financial situation, where trusts receive finance based on payment by results, accurate record keeping is very important. Many trusts have lost funding despite having a good patient load because of an inability to produce appropriate data. Information on the performance of a trust is largely obtained from data produced by clinical coding, which in turn is mainly based on information provided on the Körner Medical Records (KMR) form. The KMR is a record reflecting the number of patients admitted and discharged, the clinical problems encountered, lengths of stay and other relevant information. Most KMRs are not timely or adequately filled in due to changing shifts and junior doctors' lack of awareness.
We conducted a short audit on the appropriate completion of KMRs. The objectives were: (i) to determine the accuracy and completeness of the diagnosis noted on the KMR in relation to the clinical findings, (ii) to determine the appropriateness of sections completed, (iii) to identify any missed information (such as dates, co‐morbidities and names of associated non‐paediatric consultants) and (iv) to identify any problems experienced from the time of discharge to clinical coding leading to a delay in completing the form. According to our standards, all KMRs should have appropriate and complete information in the relevant sections and should be completed at or soon after discharge. The information to be included should consist of dates of admission and discharge, co‐morbidities, the name of any associated consultant, procedures, transfers between consultants and between hospitals, death if applicable and self‐discharge.
The data were collected retrospectively from 10th May 2005 to 24th May 2005 and included information on principal diagnosis, co‐morbidities, primary and associate consultants, primary procedure and length of time between discharge and the completion of the KMR and clinical coding. Errors were found in (i) diagnosis and clinical coding and (ii) the appropriateness of sections completed on the KMR.
There were 46 discharges. The KMR was completed for 76% of these discharges (28/46 vs 9/46). An appropriate diagnosis in relation to the clinical findings and clinical codes was noted in 68% (19/28) of KMRs, whereas 32% (9/28) of diagnoses filled in were inappropriate. Appropriate sections including information on co‐morbidities were filled in for 93% (26/28) of the KMRs. All KMRs except one were completed by 2 weeks after discharge, with most being filled in between 6 and 8 days after discharge.
We found that a large proportion of KMRs were incomplete, with missing or inappropriate diagnoses noted. Much of the data had been entered into incorrect sections and information on co‐morbidities and the name of the associate consultant were often missing. Problems observed were short admissions out of hours, temporary files and files sent to the offices of consultants or other senior clinicians for various reasons.
As the KMR is important, we recommend that it should be appropriately and accurately completed at the time of discharge along with the TTO (To Take Home) form or shortly afterwards. There is a need to increase awareness of the KMR and clinical coding among junior doctors and a process to accomplish this should be identified. Monthly feedback on clinical coding performance should be provided to specialities. In the absence of improvement, the involvement of senior staff is required.
Competing interests: None.