Good Clinical Documentation

Clinical Coders depend on clear, accurate information about all diagnoses and interventions in order
to reflect hospital activity in HIPE Data. Good clinical documentation is central to clinical coding to
provide complete hospital activity data and in turn accurate DRG assignment, resulting in
appropriate funding.

10 Tips for documentation improvement and HIPE Clinical Coding

1 Complete a discharge summary for all patients

 This information needs to be documented and substantiated throughout the
Medical Record
2 Write clearly and legibly in the notes and on discharge documentation
3 Reflect the patient’s episode of care
 Document the principal diagnosis – reason for admission
 Document any other conditions or complications that are relevant to the
episode
 Record all diagnostic and therapeutic interventions
4 Day/date and sign every entry in the notes
5 Use approved abbreviations – spell out abbreviations where there could be
ambiguity
Example: PE could be Pulmonary Embolism or Pulmonary Effusion
6 Be clear and specific– Clinical Coders cannot make inferences
7 Clearly identify procedural complications or late effects
 Using terms such as: due to, or secondary to
8 Be as specific as possible
 exact site of the fracture
 organism responsible for the infection, if known
 type of anaemia, due to blood loss, acute or chronic, aplastic, etc
 how injuries happened and where they occurred
9 Please document the following:
 The reason a test or examination is performed
 Why care or treatment is provided e.g. if a patient receives I.V. iron – please
document if the reason is to treat iron deficiency, if the reason for
administering I.V. fluids is dehydration – please document the dehydration
10 If you receive a query from a Clinical Coder in relation to documentation please
respond as soon as possible.

This document is also available on HSElanD together with a tutorial. Details of location can be found on the
page below.
For further information on Clinical Coding and HIPE please contact the HIPE Department at your hospital.
For information on the work of the HPO and clinical coding please refer to www.hpo.ie
Source: Healthcare Pricing Office. V1.1
 Good Clinical Documentation and HIPE Clinical Coding

Clinical documentation
The quality of clinical documentation in the healthcare record is essential to:
 Ensure the continuity and delivery of safe, quality healthcare for patients.
 Document and facilitate communication of care between the patient, their family and
healthcare teams and provide evidence of same.
See: https://www.hse.ie/eng/about/who/qid/quality-and-patient-safety-documents/v3.pdf
www.hpo.ie

Hospital In-Patient Enquiry (HIPE) collects Activity data on Inpatient and Day cases in all Acute
Public hospitals in Ireland based on the information available in the patient’s healthcare record.
 A HIPE record is created when a patient is discharged from (or dies in) hospital.
 Each HIPE record contains administrative, demographic and clinical information.
 A HIPE coded record contains
 A Principal diagnosis (the reason the patient was admitted to hospital), and can
collect up to 29 additional diagnoses, as appropriate.
 A Principal Procedure, and up to 19 additional procedures can be collected, as
appropriate.

The Medical Record

The Clinical Coder reviews the entire medical record, including:
Clinical Notes, Hospital information systems, Discharge Summary, Operation/Theatre information,
Histology reports, Sepsis forms, Nursing Notes, Allied Health documentation. The Clinical Coder can
only assign codes for diagnoses and interventions that are documented in the medical record.

Clinical Coders depend on clear, accurate information about all diagnoses and interventions in order
to reflect hospital activity in HIPE Data. Good clinical documentation is central to clinical coding to
provide complete hospital activity data and in turn accurate DRG assignment, resulting in
appropriate funding.

If it isn’t documented it didn’t happen

Clinical coding
The relevant clinical information is abstracted from the patient’s medical record by a trained Clinical
Coder and is translated into coded data using the International Statistical Classification of Diseases,
10th revision, Australian Modification & the Australian Classification of Health Interventions and
Australian Coding Standards (ICD-10-AM/ACHI/ACS). The coded data is entered and validated
through the HIPE Portal, and is submitted monthly to the Healthcare Pricing Office (HPO).

HIPE Data
HIPE Data have many applications, including patient safety, quality improvement, Health Service
planning and Activity Based Funding (ABF). HIPE Data are increasing being used by the Clinical
Programmes, and by the National Office of Clinical Audit (NOCA).

This document is also available on HSElanD together with a tutorial. Details of location can be found on the
page below.
For further information on Clinical Coding and HIPE please contact the HIPE Department at your hospital.
For information on the work of the HPO and clinical coding please refer to www.hpo.ie

Source: Healthcare Pricing Office. V1.1

 The Use of Test Results in Clinical Coding

Coding standards provide clear instructions regarding the use of test results by clinical coders, guiding them on
when they may or may not be used.

Clinical Coders can use test results to add specificity to an already documented diagnosis
Codes can be assigned in the following circumstances:
 Fracture of subcapital section of the femur where documentation shows fracture neck of femur and x-
ray results shows subcapital fracture.
 Acute bronchiolitis due to respiratory syncytial virus where documentation shows bronchiolitis and
cytology confirms RSV as causative agent.

Clinical Coders cannot assign codes based on abnormal test findings alone – the condition must be
documented by the treating Clinician.
Unless a clinician can indicate that a test result is significant and/or indicates the relationship between an
unclear test result and a condition, such test results should not be coded.

Codes cannot be assigned in the following circumstances:

 Urinary tract infection where only microbiology results shows organism(s) have been cultured.
 Pulmonary collapse where x-ray shows basal atelectasis.
 Peritoneal adhesions where shown on CT report in a case of a principal diagnosis of abdominal
pain.
 Leiomyoma of uterus included on histopathology when the reason for hysterectomy is
documented as menorrhagia.

Source: Australian Coding Standard 0010 General Abstraction Guidelines

This document is also available on HSElanD together with a tutorial. Details of location can be found on the
page below.
For further information on Clinical Coding and HIPE please contact the HIPE Department at your hospital.
For information on the work of the HPO and clinical coding please refer to www.hpo.ie

Source: Healthcare Pricing Office. V1.1

Source: Healthcare Pricing Office. V1.1