Diagnosis by ICD coding on discharge and death: A medical record-based study on in-patients of a Medical College and Hospital of West Bengal, India

Abstract

Introduction: Medical records of hospitals are primary and basic source of health information. It provides background and clinical diagnosis, treatment undertaken, complications, length of stay, laboratory date etc. which plays an important role in planning health care services. International Classification of Diseases (ICD) helps in managing health information, data standardization, and classification of patients’ health information maintaining uniformity globally.

Objectives: To find out the socio-demographics, final diagnosis and status of ICD coding at discharge or death.

Materials and Methods: It was an analysis of one-month secondary data, 3002 in number from Medical Records Department of a Medical College of Eastern India. Along with this, two key informants (KI), one medical and one non-medical were interviewed. UCINET was used for network analysis besides descriptive statistics.

Results: Mean age of participants was 53.03±15.89 years, 2407 (80.18%) received medical management and 595 (19.82%) underwent surgical interference. In 164 records ICD coding was missing, among them 131 were left against medical advice, 24 died during the hospital stay and 9 patients were discharged as cured. Thematic analysis of gaps, concerns and solutions some consensus was found as, lack of corroboration, no linkage between prescriber and coder, manpower shortage, the need of training and so on.

Conclusions: ICD is one of the most scientific, universally acceptable and important classification systems having overarching applicability. Interdepartmental collaborative record updatation by trained manpower is very much needed for making the hospital record keeping system more sound and stringent.