Do we do what they say we do? Coding errors in urology

Objective To determine the accuracy of routine data coding in a large multi speciality urological unit. Materials and methods From the clinical records, the diagnosis and procedur e codes were ascribed to 106 finished consultant episodes (FCEs) in urology , by two urological trainees. The codes were compared with those ascribed b y professional hospital coders land of which the trainees were unaware) fro m information written on the audit form by junior medical staff. Where ther e were discrepancies in codes an error was recorded and the stage in the co ding process in which it occurred was determined. Results Forty-eight coding errors were found in 38 of the 106 (36%) FCEs; 3 4 (71%) were caused by inaccurate coding and 14 (29%) were the result of th e incorrect completion of audit forms, Conclusion The clinical codes generated from the authors' department do not accurately reflect the clinical practice. If coding errors of this magnitu de are typical of urology units in general, the concept of hospital perform ance tables (which will be generated using routine clinical data) is untena ble unless data recording is given higher priority.