Capturing causative agents in clinical coding

Background: At least 14.6% of paediatric hospital episodes in England were due to infections in 2014/15. The clinical coding of infection aetiology is required for healthcare planning, epidemiology and financial reimbursement. The degree to which causative agents are recorded in infection coding datasets is unknown, and its importance for remuneration and other secondary uses has not been studied. Methods: An audit of bronchiolitis admissions to a London children's hospital was performed between 1 August 2014 and 31 July 2015. The agreement between the discharge documentation, coding reports and results of a Respiratory Virus Molecular Panel was assessed by clinicians and a coding professional. The impact of errors on data quality and finances was reviewed. Results: Of the 74 admissions, 52 (70.3%) did not have identified causative agents accurately represented in the coding, with inadequate clinical documentation being the leading cause (53.8%). In total, 29 hospital admissions were assigned to an incorr...