Health information management : journal of the Health Information Management Association of Australia最新文献

{"title":"Read science news critically and look for original studies: An example of misleading headlines related to COVID-19 vaccines in mainstream media.","authors":"Petar Milovanovic","doi":"10.1177/18333583211060034","DOIUrl":"https://doi.org/10.1177/18333583211060034","url":null,"abstract":"In July 2021, after a representative of the Serbian health authorities had cited a recent study from Sri Lanka in the media that the Sinopharm antiCOVID-19 vaccine (BBIBPCorV) was very effective against the Delta strain of SARSCoV-2, I tried to locate the original study. The headlines in the Serbian media read: ‘Sinopharm is the most effective vaccine against the delta variant, studies show’ (RTS, 2021). While conducting a simple online search using a combination of keywords, I was surprised to come across several articles in the English language with headlines suggesting that the Sinopharm vaccine is not effective against the Delta strain (‘Sinopharm’s COVID-19 shot induces weaker antibody responses to Delta -study shows’) (Reuters, 2021). Unfortunately, most people will not read the full articles, let alone attempt to locate the original study to locate the actual results. Reading the full text of the original manuscript revealed that the Sri Lankan study (Jeewandara et al., 2021) had reported that the titre of specific antibodies was comparable between Sinopharm-vaccinated individuals and those who survived a natural infection with the Delta variant. Another observation reported in the study was that the titre of antibodies specific to the Delta strain in vaccinated individuals was lower than that of the original Wuhan variant. It was clear from the text of the original study that the authors had not actually compared the different vaccines; thus, the headlines in the Serbian media implying that this vaccine was ‘the most effective’ had not accurately described the cited research. Nevertheless, the Serbian media headlines correctly emphasised the protection aspect, given that the vaccine obviously offers seroconversion comparable to that of a natural infection. In contrast, the English-language media headlines wrongly emphasised that the vaccine offers a ‘weaker response to Delta’; the study actually showed a weaker response compared with the Wuhan variant, but similar to a natural infection with the Delta strain. These authors had not studied the effectiveness of the vaccine in preventing infection, hospitalisation or death; rather, they had focused on the evaluation of specific antibodies and T-cell responses. Of note, this was a manuscript uploaded to a preprint server and not a peer-reviewed article; it should also have been read critically andwill, hopefully, soon go through fair review by experts in the field. In the meantime, this is an exemplary case of how easy it is to misinterpret research findings, and how easily some of the ‘fake news’ develops. Special care is needed to avoid cases such as this, to avoid further erosion of people’s trust in health systems and vaccines protecting against COVID-19. This case is also a beautiful reminder that we should always refer to the primary literature.","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":"52 2","pages":"132"},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10170247/pdf/10.1177_18333583211060034.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10501352","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of implementing structured note templates on data capture for hernia surgery.","authors":"Christopher David Vetter,&nbsp;John H Kim","doi":"10.1177/18333583211001584","DOIUrl":"https://doi.org/10.1177/18333583211001584","url":null,"abstract":"<p><strong>Background: </strong>Electronic medical record notes have been determined to be lacking in quality, accessibility and content. Structured note templates could provide a way to improve these aspects, particularly with regard to data availability for research and quality improvement.</p><p><strong>Objective: </strong>To determine whether the implementation of a standardised template for hernia documentation can improve data completeness and timeliness.</p><p><strong>Method: </strong>Retrospective review of clinic notes of 30 patients, 15 prior to implementation of a standardised note template and 15 after implementation of the template. The number of the 21 Americas Hernia Society Quality Collaborative (AHSQC) variables which were present in the notes was recorded, as was the time that the consultation ended and the time that the note was submitted.</p><p><strong>Results: </strong>Mean number of variables collected prior to implementation of the template was 5.9 ± 1.6 vs. 20 ± 0.4 after implementation (<i>p</i> < 0.001). In the pre-implementation group, 20% of the notes were completed after the day of the visit, while all of the notes in the post-implementation group were completed on the same day as the visit (<i>p</i> = 0.367).</p><p><strong>Conclusion: </strong>Implementation of a structured note template resulted in significantly improved capture of specific database variables within clinical notes. Structured note templates are an effective tool to improve data capture from the clinical setting for research and quality improvement.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":"52 2","pages":"87-91"},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/18333583211001584","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9821374","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Innovations in clinical documentation integrity practice: Continual adaptation in a data-intensive healthcare organisation.","authors":"Kathleen H Pine,&nbsp;Lee Anne Landon,&nbsp;Claus Bossen,&nbsp;M E VanGelder","doi":"10.1177/18333583211067845","DOIUrl":"https://doi.org/10.1177/18333583211067845","url":null,"abstract":"<p><strong>Background: </strong>Numbers of clinical documentation integrity specialists (CDIS) and CDI programs have increased rapidly. CDIS review patient records concurrently with patient admissions and visits to ensure that information is accurate, complete and non-ambiguous, and query clinicians when they see opportunities for improving data. The occupation was initially focused on improving data for reimbursement, but rapid changes to clinical coding requirements, technologies and payment systems led to a quickly evolving role for CDI programs and changes in CDIS practice.</p><p><strong>Objective: </strong>This case study seeks to uncover the ongoing innovation and adaptation occurring in a CDI program by tracing the evolution of a single CDI program over time.</p><p><strong>Method: </strong>We present a case study of the CDI program at the HonorHealth hospital system in Arizona.</p><p><strong>Results: </strong>The HonorHealth CDI program holds a unique hybrid expertise and role within the healthcare organisation that allows it to rapidly adapt to support emergent demands both internal and external to the organisation, such as supporting accurate data collection for the COVID-19 pandemic.</p><p><strong>Conclusion: </strong>CDIS are a vital component in present data-intensive resourcing efforts. The hybrid expertise of CDIS and capacity for adaption and relationship building has enabled the HonorHealth CDI program to adapt rapidly to meet a growing array of clinical documentation integrity needs, including emergent needs during the COVID-19 pandemic.</p><p><strong>Implications: </strong>The HonorHealth case study can guide other CDI programs in adaptation of the CDI role and practices in response to changing organisational needs.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":"52 2","pages":"119-124"},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9804318","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Can electronic assessment tools improve the process of shared decision-making? A systematic review.","authors":"Nyantara Wickramasekera, Sarah K Taylor, Elizabeth Lumley, Thomas Gray, Emma Wilson, Stephen Radley","doi":"10.1177/1833358320954385","DOIUrl":"10.1177/1833358320954385","url":null,"abstract":"<p><strong>Background: </strong>Patient involvement in decision-making plays a prominent role in improving the quality of healthcare. Despite this, shared decision-making is not routinely implemented. However, electronic assessment tools that capture patients' history, symptoms, opinions and values prior to their medical appointment are used by healthcare professionals during patient consultations to facilitate shared decision-making.</p><p><strong>Objective: </strong>To assess the effectiveness of electronic assessment tools to improve the shared decision-making process.</p><p><strong>Method: </strong>A systematic review was conducted following PRISMA guidelines. Published literature was searched on MEDLINE, EMBASE and PsycINFO to identify potentially relevant studies. Data were extracted and analysed narratively.</p><p><strong>Results: </strong>Seventeen articles, representing 4004 participants, were included in this review. The main findings were significant improvement in patient-provider communication and provider management of patient condition in the intervention group compared to the control group. In contrast, patient-provider satisfaction and time efficiency were assessed by relatively few included studies, and the effects of these outcomes were inconclusive.</p><p><strong>Conclusion: </strong>This review found that communication and healthcare professional's management of a patient's condition improves because of the use of electronic questionnaires. This is encouraging because the process of shared decision-making is reliant on high-quality communication between healthcare professionals and patients.</p><p><strong>Implications: </strong>We found that this intervention is especially important for people with chronic diseases, as they need to establish a long-term relationship with their healthcare provider and agree to a treatment plan that aligns with their values. More rigorous research with validated instruments is required.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":"52 2","pages":"72-86"},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10170559/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9444091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The emergence of health information in aged care.","authors":"Carol Loggie,&nbsp;Jenny Davis","doi":"10.1177/18333583221128339","DOIUrl":"https://doi.org/10.1177/18333583221128339","url":null,"abstract":"Aged care in Australia has historically operated in the shadow of health care. However, recent dramatic changes have raised the profile of aged care into the spotlight, due largely to the devastating impact of the COVID-19 pandemic on the older population and the alarming findings of the Royal Commission into Aged Care Quality (2021). However, the impetus for change had already been intensifying. Policy development, regulation and funding of aged care services is the responsibility of the Australian Government (Australian Government Department of Health, 2021: 9). Since the late 1990s, in response to the challenges associated with the expanding population of older people, Government policy has aimed to keep people living at home for as long as possible by increasing funding for care and service delivery in the home and community (Australian Government Aged Care Financing Authority, 2020: 7). With residential aged care only being available for those with the highest level of care needs, there has been an increasing complexity in the needs of older people living in the community. Consequently, there is a heavy reliance on a broad range of aged care services for thosewho are living in their own homes, and increased acuity in the needs of residents in care. The result is an aged care sector of many fragmented parts, which presents a myriad of difficulties for older people and their families, for aged care providers, and indeed for governments in planning, funding, and managing services (Davis et al., 2017). To ensure older people have choice and access to appropriate and timely care that delivers the most optimal outcomes, there is a critical need for improvement in aged care health information systems (Sendall et al., 2017). A Virtual Special Issue of the Health Information Management Journal on The Emergence of Health Information in Aged Care, guest edited by Carol Loggie and Jenny Davis, includes recent articles that explore different aspects of information systems and technologies for aged care across three main themes: considerations for the needs and key issues of health information in aged care; innovation and progress in the sector; and future opportunities (see Box 1). Together they highlight the key issues and provide a comprehensive overview of the current context and implications for the future. Considerations for health information in aged care: needs and key issues at three levels","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":"52 2","pages":"59-63"},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9541561","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is training doctors in medical certification effective? Evidence from a prospective study in the Philippines.","authors":"Jomilynn Rebanal,&nbsp;Tim Adair,&nbsp;Lene Mikkelsen","doi":"10.1177/18333583211059229","DOIUrl":"https://doi.org/10.1177/18333583211059229","url":null,"abstract":"<p><strong>Background: </strong>Correct certification of causes of death by physicians according to International Classification of Diseases (ICD) rules is essential to generate mortality statistics of the quality needed to guide public health policy debates and reliably monitor the impact of health interventions. Several efforts to train doctors have been undertaken in the Philippines to improve Medical Certification of Causes of Death (MCCOD). However, there is very little evidence about the long-term effects of training interventions for medical certification.</p><p><strong>Objective: </strong>To test whether there were measurable long-term impacts of this large-scale training intervention for improving medical certification and reducing different types of certification errors.</p><p><strong>Method: </strong>We assessed the quality of 2100 MCCOD completed before face-to-face training with those written by the same doctors 6 months after the training. An assessment tool was used to evaluate the quality of MCCOD.</p><p><strong>Results: </strong>Less than 1% of the 2100 MCCOD assessed prior to the training were completely error-free, increasing to 19.2% 6 months after the training. On average, the number of errors per certificate fell from 2.2 pre-training to 1.3, six months after training. Importantly, there was a 38% decrease in writing ill-defined causes on the last line, which is particularly important for the policy utility of data.</p><p><strong>Conclusion: </strong>Training doctors in correct medical certification can have a long-term impact on medical certification practices.</p><p><strong>Implications: </strong>Shorter, more focused, trainings that address the most common medical certification errors could have an even greater impact on medical certification practices.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":"52 2","pages":"101-107"},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9794709","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The historiography of a profession: The societal and political drivers of the health information management profession in Australia.","authors":"Kerin Robinson,&nbsp;Simon Barraclough,&nbsp;Elizabeth Cummings,&nbsp;Rick Iedema","doi":"10.1177/18333583211070336","DOIUrl":"https://doi.org/10.1177/18333583211070336","url":null,"abstract":"<p><p>Health information permeates healthcare delivery from point-of-care, across the continuum of care and throughout the healthcare system's policy, population health, research, planning and funding arenas. Health information managers (HIMs) expertly manage that information. This commentary theorises the health information management profession for the first time. Its purpose is to identify and contextualise, via a historiographical account, the societal and political drivers that have shaped contemporary Australian health information management and HIMs' scientific work. It seeks to build our knowledge of the socio-political influences on the profession's emergence and development, and the projected drivers of its future. Eight critical, socio-political drivers were identified and are addressed in temporaneous order. <i>Scientific medicine</i> has reflected the influences on medicine in the past century and a half of the medical record and other technologies, laboratory-based sciences, evidence-based medicine and evidence-based health. <i>Standardisation</i> has underpinned and guided the profession's practice. <i>The hegemony of non-medical healthcare managers</i> and resource- and performance-related accountabilities emerged in the 1960s, as did the efficiencies of <i>bureaucratisation</i> in healthcare and post-bureaucratic shifts to textualisation and technogovernance. <i>Technologisation</i> has driven constant change in health information management, as have the forces of the fast-paced <i>risk society</i>. Since the 1980s, the <i>health consumer movement</i> has propelled regulatory mechanisms that accord patients' access rights to their medical records and mandate information privacy protections. Finally, a nascent <i>commodification of health information</i> has emerged. These forces exert ongoing impacts on the profession. They will, we conclude, singularly and collectively continue to shape its discourses and direction.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":"52 2","pages":"64-71"},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9418717","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Completeness and accuracy of adverse drug reaction documentation in electronic medical records at a tertiary care hospital in Australia.","authors":"Gina McLachlan,&nbsp;Airley Broomfield,&nbsp;Rohan Elliott","doi":"10.1177/18333583211057741","DOIUrl":"https://doi.org/10.1177/18333583211057741","url":null,"abstract":"<p><p><b>Background:</b> A large proportion of patients presenting to hospitals have experienced a previous adverse drug reaction (ADR). Electronic medical records (EMRs) present an opportunity to accurately document ADRs and alert clinicians against inadvertent rechallenge where there is a pre-existing reaction. However, EMR systems are imperfect and rely on the accuracy of the data entered. <b>Objective:</b> To ascertain the completeness of ADR documentation and the accuracy of the classification of ADRs as allergy versus intolerance in the EMR at a major metropolitan hospital in Australia. <b>Method:</b> Cross-sectional audit of the ADR field of the EMR for a sample of patients on four different wards over 3 weeks to ascertain the completeness of ADR documentation and the accuracy of classification of ADRs. <b>Results:</b> Of the 264 patients assessed, 102 (38.6%) had a total of 210 ADRs documented in the EMR. Of these, 105 (50%) were considered to have complete documentation; 63/210 (30.0%) were missing a reaction description and 88/210 (41.9%) were missing severity information. For those ADRs with a reaction description (<i>n</i> = 147), 97 (66.0%) were considered to be appropriately classified as allergy or intolerance. <b>Conclusion:</b> Incomplete and inaccurate ADR documentation was common. These findings highlight a need for optimising ADR documentation to improve appropriate medication use in hospital. Implications: Improved EMR design and education of healthcare workers on the importance of complete and accurate documentation of reactions are needed to improve completeness and accuracy of ADR classification.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":"52 2","pages":"108-111"},"PeriodicalIF":0.0,"publicationDate":"2023-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9804319","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Social media in health communication: A literature review of information quality.","authors":"Eric Afful-Dadzie,&nbsp;Anthony Afful-Dadzie,&nbsp;Sulemana Bankuoru Egala","doi":"10.1177/1833358321992683","DOIUrl":"https://doi.org/10.1177/1833358321992683","url":null,"abstract":"<p><strong>Background: </strong>Social media is used in health communication by individuals, health professionals, disease centres and other health regulatory bodies. However, varying degrees of information quality are churned out daily on social media. This review is concerned with the quality of Social Media Health Information (SMHI).</p><p><strong>Objective: </strong>The review sought to understand how SMHI quality issues have been framed and addressed in the literature. Health topics, users and social media platforms that have raised health information quality concerns are reviewed. The review also looked at the suitability of existing criteria and instruments used in evaluating SMHI and identified gaps for future research.</p><p><strong>Method: </strong>The Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the forward chaining strategy were used in the document search. Data were sourced according to inclusion criteria from five academic databases, namely Scopus, Web of Science, Cochrane Library, PubMed and MEDLINE.</p><p><strong>Results: </strong>A total of 93 articles published between 2000 and 2019 were used in the review. The review revealed a worrying trend of health content and communication on social media, especially of cancer, dental care and diabetes information on YouTube. The review further discovered that the <i>Journal of the American Medical Association</i>, the DISCERN and the Health on the Net Foundation, which were designed before the advent of social media, continue to be used as quality evaluation instruments for SMHI, even though technical and user characteristics of social media differ from traditional portals such as websites.</p><p><strong>Conclusion: </strong>The study synthesises varied opinions on SMHI quality in the literature and recommends that future research proposes quality evaluation criteria and instruments specifically for SMHI.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":"52 1","pages":"3-17"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1833358321992683","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9086606","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Verification of administrative data to measure palliative care at terminal hospital stays.","authors":"Joanne M Stubbs,&nbsp;Hassan Assareh,&nbsp;Helen M Achat,&nbsp;Sally Greenaway,&nbsp;Poorani Muruganantham","doi":"10.1177/1833358320968572","DOIUrl":"https://doi.org/10.1177/1833358320968572","url":null,"abstract":"<p><strong>Background: </strong>Administrative data and clinician documentation have not been directly compared for reporting palliative care, despite concerns about under-reporting.</p><p><strong>Objective: </strong>The aim of this study was to verify the use of routinely collected administrative data for reporting in-hospital palliation and to examine factors associated with coded palliative care in hospital administrative data.</p><p><strong>Method: </strong>Hospital administrative data and inpatient palliative care activity documented in medical records were compared for patients dying in hospital between 1 July 2017 and 31 December 2017. Coding of palliative care in administrative data is based on hospital care type coded as \"palliative care\" and/or assignment of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) palliative care diagnosis code Z51.5. Medical records were searched for specified keywords, which, read in context, indicated a palliative approach to care. The list of keywords (palliative, end of life, comfort care, cease observations, crisis medications, comfort medications, syringe driver, pain or symptom management, no cardiopulmonary resuscitation, advance medical plan/resuscitation plan, deteriorating, agitation, restless and delirium) was developed in consultation with seven local clinicians specialising in palliative care or geriatric medicine.</p><p><strong>Results: </strong>Of the 576 patients who died in hospital, 246 were coded as having received palliative care, either solely by the ICD-10-AM diagnosis code Z51.5 (42%) or in combination with a \"palliative care\" care type (58%). Just over one-third of dying patients had a palliative care specialist involved in their hospital care. Involvement of a palliative care specialist and a cancer diagnosis substantially increased the odds of a Z51.5 code (odds ratio = 11 and 4, respectively). The majority of patients with a \"syringe driver\" or identified as being at the \"end of life\" were assigned a Z51.5 code (73.5% and 70.5%, respectively), compared to 53.8% and 54.7%, respectively, for \"palliative\" or \"comfort care.\" For each keyword indicating a palliative approach to care, the Z51.5 code was more likely to be assigned if the patient had specialist palliative care input or if they had cancer.</p><p><strong>Conclusion: </strong>Our results suggest administrative data under-represented in-hospital palliative care, at least partly due to medical record documentation that failed to meet ICD-10-AM coding criteria. Collaboration between clinicians and coders can enhance the quality of records and, consequently, administrative data.</p>","PeriodicalId":73210,"journal":{"name":"Health information management : journal of the Health Information Management Association of Australia","volume":"52 1","pages":"28-36"},"PeriodicalIF":0.0,"publicationDate":"2023-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1177/1833358320968572","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"9086592","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}