[WWW - 2023.07.31]

Data Element Detail

Incomplete coded episode of admitted patient care-reason for incomplete clinical coding
Identifying and Definitional Attributes
QH 041585 v1
Data Element
Data Element
Draft
26-Oct-2012		Current
25-Jan-2013
Standard
01-Jul-2012
The reason the clinical coding for an episode of admitted patient care has not been completed.
Admitted patient care
Reason for incomplete clinical coding
Incomplete coding, Reason for incomplete coding
Representational Attributes
Alphabetic
Code
A(4)
4
4
Permissible Values

Permissible_values

CodeDescription
ADMNAwaiting clarification on admission details
AUDTAwaiting coding audit review
CLINAwaiting clinical clarification
DISCAwaiting discharge summary completion
DOCOIncomplete documentation
IMAGAwaiting imaging results
INTEInterrupted clinical coding process
NATQAwaiting national query response
PATHAwaiting pathology results
QLDQAwaiting state query response
UNAVClinical record unavailable
Supplementary Values

Supplemenary_values

-
Collection and Usage Attributes
To be collected when the clinical coding for the episode of admitted patient care is deemed incomplete.

Where coding for an episode of admitted patient care is deemed to be incomplete for multiple reasons, a code value representing the most significant reason is assigned.

Once the clinical coding is considered complete for an episode of care, the Reason for incomplete clinical coding value is deleted.

ADMN Awaiting clarification on admission details
Clinical coding is incomplete because there is an issue with the admission details that requires clarification in order for the correct assignment of clinical codes.

AUDT Awaiting coding audit review
Clinical coding is incomplete because the episode of care has been selected for audit review of the clinical coding. Excludes retrospective auditing (i.e. after the episode has been completed for coding purposes).

CLIN Awaiting clinical clarification
Clinical coding is incomplete because clinical statements within the clinical record require clarification by a clinician in order to correctly assign clinical codes.

DISC Awaiting discharge summary completion
Clinical coding is incomplete because a discharge summary is incomplete or missing in the clinical record.

DOCO Incomplete documentation
Clinical coding is incomplete because documentation (other than imaging, pathology or discharge summary) in the clinical record is incomplete or missing.

IMAG Awaiting imaging results
Clinical coding is incomplete because imaging results are required to complete the code allocation.

INTE Interrupted clinical coding process
Clinical coding is incomplete because the Clinical Coder was interrupted and unable to complete the code allocation.

NATQ Awaiting national query response
Clinical coding is incomplete because component(s) within a clinical record require clarification from a national committee prior to code allocation.

PATH Awaiting pathology results
Clinical coding is incomplete because component(s) within the record require review of pathology results prior to code allocation.

QLDQ Awaiting state query response
Clinical coding is incomplete because component(s) within a clinical record require clarification from the Queensland Coding Network prior to code allocation.

UNAV Clinical record unavailable
Clinical coding is incomplete because the clinical record is currently unavailable to complete the coding process.
Episode of admitted patient care-clinical coding status must be 2 (Started - incomplete).
Hospital Based Corporate Information System (HBCIS):
At the Inpatient ICD Coding screen the record is filed (saved) and, where the episode of admitted patient care is deemed to be incomplete for clinical coding purposes, the deficiency reason is selected.

Once the record is considered complete for clinical coding purposes, HBCIS is to be updated by removing the 'INCOMP CODING' reason code from display.
Clinical coding of an episode of admitted patient care involves the assignment of ICD-10-AM (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification) and/or ACHI (Australian Classification of Health Related Problems) codes according to Australian coding standards and coding convention.
Relational Attributes
Related Metadata References

Related Metadata References_IR

  • 1 - 2
ViewRelationshipMetadata Item TypeMetadata Item SubtypeNameIdentifier & VersionApproval Status
Is used in the derivation ofData ElementData ElementEpisode of admitted patient care-clinical coding statusQH 041607 Version 1Current
Relates toData ElementData Element ConceptIncomplete coded episode of admitted patient careQH 041608 Version 1Current
Implementation in Metadata Sets

Implemented

No Metadata Items
Source and Reference Attributes
Clinical coding; Coding; Incomplete coding; Morbidity codes;