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A cohort study on physician documentation and the accuracy of administrative data coding to improve passive surveillance of transient ischaemic attacks.

Amy Ying Xin YuHude QuanAndrew D McRaeGabrielle O WagnerMichael D HillShelagh B Coutts
Published in: BMJ open (2017)
In suspected patients with TIA and minor stroke presenting to the ED, physician documentation was the dominant factor in coding accuracy, supporting the concept that physicians are active participants in administrative data coding. Strategies to improve chart documentation are predicted to have a positive effect on coding accuracy.
Keyphrases
  • electronic health record
  • primary care
  • emergency department
  • advance care planning
  • public health
  • atrial fibrillation
  • pulmonary embolism
  • case report
  • artificial intelligence