معايير تطبيق الترميز الصحي

• Practice Standards:

• Members of the Clinical Coders’ Society of Australia will strive to observe and abide by the following practice standards:

• In order to assign codes for a particular patient episode of care or encounter, carry out a thorough review of documentation in the clinical record pertinent to that episode.
• Use documentation in that episode of care or encounter to support the diagnoses and procedures selected for coding.
• Use definitions of the National Health Data Dictionary to select, code and sequence diagnoses and procedures.
• Use their skills and knowledge of the current Australian coding system, the Australian Coding Standards and any other available resources, including clinician consultation, to select, sequence and code diagnoses and procedures.
• Not code diagnoses or procedures that are not substantiated by documentation within the medical record.
• Initiate and maintain communication with other health care professionals and relevant organisations to improve the quality of documentation and accuracy of coding.
• Participate in quality improvement activities to ensure the quality of coding is maintained.
• Ensure coding accuracy is maintained in accordance with work experience accuracy rates
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