Which of the following is an appropriate method of coding in the filing procedure?

Ann Saudi Med. 2005 Jan-Feb; 25[1]: 46–49.

Abstract

BACKGROUND

Since the medical record is the major source of health information, it is necessary to maintain accurate, comprehensive and properly coded patient data. We reviewed 300 medical records from patients at King Faisal Specialist Hospital and Research Center, representing four departments [medicine, surgery, pediatrics and obstetrics and gynecology].

METHODS

The records were audited following the guidelines of the International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] for accuracy and completeness of documentation and coding of primary and secondary diagnoses and procedures performed.

RESULTS

Of 1051 items abstracted, 876 [83.3%] were accurately documented, 41 [3.9%] were inaccurately documented, and 134 [12.7%] were not documented. Of the items abstracted, 736 [70%] were assigned a correct code, 110 [10.5%] were assigned an incorrect code, and 205 [19.5%] were not coded. More items classified as accurately documented were coded correctly [71.1%] than items inaccurately documented [49.7%] [P