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Health Information Managers (HIMs) and Clinical Coders (CCs) are responsible for the translation of the inpatient episode into diagnosis and procedure codes, in compliance with the Australian Coding Standards for ICD-10-AM and ACHI.
The HIMs and CCs are also responsible for ensuring that the relevant documentation by clinicians accurately reflects the inpatient stay.
Read the two journal articles listed below. In these articles, the authors discuss issues related to documentation by clinicians and the abstraction of diagnoses and procedures by HIMs and CCs for injuries and nosocomial complications.
Statements for discussion in your team’s on-line forum ( Minimum 350-400 words comments based on below questions)
1.  The use of ‘unspecified’ codes by HIMs and CCs, when they are coding injuries and nosocomial complications, is often a result of inadequate documentation by clinicians.
i)  Do you agree with this statement, or not? Justify your decision based on the information in the articles.
ii)  What are the potential implications for each of the major parties/stakeholders in the coded data?
2.  The quality of coded data is compromised by the HIMs’ / CCs’ inexperience in coding or lack of clinical knowledge.
i)  Do you agree with this statement, or not? Justify your decision.
ii)  How might this situation be rectified?
iii)  What are the potential implications of poor/lesser quality of coded data?
3.  The classification used for assigning diagnosis and procedure codes for injuries and nosocomial complications in Australia needs improvement.
i)  Do you agree with this statement, or not? Justify your decision.
ii)  If you agree, what aspects/areas need to be improved upon?
iii)  How, do you think, might any improvements be made?

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