{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,6]],"date-time":"2026-01-06T13:15:06Z","timestamp":1767705306573},"reference-count":10,"publisher":"Wiley","issue":"7","license":[{"start":{"date-parts":[[2013,7,11]],"date-time":"2013-07-11T00:00:00Z","timestamp":1373500800000},"content-version":"vor","delay-in-days":10,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Internal Medicine Journal"],"published-print":{"date-parts":[[2013,7]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Background<\/jats:title><jats:p>Accurate and comprehensive clinical documentation is crucial for effective ongoing patient care, follow up and to optimise casemix\u2010based funding. Each <jats:styled-content style=\"fixed-case\">D<\/jats:styled-content>iagnostic <jats:styled-content style=\"fixed-case\">R<\/jats:styled-content>elated <jats:styled-content style=\"fixed-case\">G<\/jats:styled-content>roup (<jats:styled-content style=\"fixed-case\">DRG<\/jats:styled-content>) is assigned a \u2018weight\u2019, leading to <jats:styled-content style=\"fixed-case\">W<\/jats:styled-content>eighted <jats:styled-content style=\"fixed-case\">I<\/jats:styled-content>nlier <jats:styled-content style=\"fixed-case\">E<\/jats:styled-content>quivalent <jats:styled-content style=\"fixed-case\">S<\/jats:styled-content>eparation (<jats:styled-content style=\"fixed-case\">WIES<\/jats:styled-content>), a system many public and private hospitals in <jats:styled-content style=\"fixed-case\">A<\/jats:styled-content>ustralia subscribe to.<\/jats:p><\/jats:sec><jats:sec><jats:title>Aims<\/jats:title><jats:p>To identify the top <jats:styled-content style=\"fixed-case\">DRG<\/jats:styled-content> in a general medical inpatient service, the completeness of medical discharge documentation, commonly missed comorbidities and system\u2010related issues and subsequent impact on <jats:styled-content style=\"fixed-case\">DRG<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">WIES<\/jats:styled-content> allocation.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>One hundred and fifty completed discharge summaries were randomly selected from the top 10 medical <jats:styled-content style=\"fixed-case\">DRG<\/jats:styled-content> in our health service. From a detailed review of the clinical documentation, principal diagnoses, associated comorbidities and complications, where appropriate, the <jats:styled-content style=\"fixed-case\">DRG<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">WIES<\/jats:styled-content> were modified.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>Seventy\u2010two (48%) of the 150 reviewed admissions resulted in a revision of <jats:styled-content style=\"fixed-case\">DRG<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">WIES<\/jats:styled-content> equivalent to an increase of <jats:styled-content style=\"fixed-case\">AUD<\/jats:styled-content> 142\u2009000. Respiratory\u2010based <jats:styled-content style=\"fixed-case\">DRG<\/jats:styled-content> generated the largest revision of <jats:styled-content style=\"fixed-case\">DRG<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">WIES<\/jats:styled-content>, while \u2018<jats:styled-content style=\"fixed-case\">C<\/jats:styled-content>ellulitis\u2019 <jats:styled-content style=\"fixed-case\">DRG<\/jats:styled-content> had the largest relative change. Twenty\u2010seven per cent of summaries reviewed necessitated a change in coding with no subsequent change in <jats:styled-content style=\"fixed-case\">DRG<\/jats:styled-content> allocation or <jats:styled-content style=\"fixed-case\">WIES<\/jats:styled-content>. Acute renal failure, anaemia and electrolyte disturbances were the most commonly underrepresented entities in clinical discharge documentation. Seven patients had their <jats:styled-content style=\"fixed-case\">WIES<\/jats:styled-content> downgraded.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>Comprehensive documentation of principal diagnosis\/diagnoses, comorbidities and their complications is imperative to optimal <jats:styled-content style=\"fixed-case\">DRG<\/jats:styled-content> and <jats:styled-content style=\"fixed-case\">WIES<\/jats:styled-content> allocation. Regular meetings between clinical and coding staff improve the quality and timeliness of medical documentation, ensure adequate communication with general practitioners and lead to appropriate funding.<\/jats:p><\/jats:sec>","DOI":"10.1111\/imj.12084","type":"journal-article","created":{"date-parts":[[2013,1,24]],"date-time":"2013-01-24T17:40:17Z","timestamp":1359049217000},"page":"767-771","update-policy":"http:\/\/dx.doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":14,"title":["Review of medical discharge summaries and medical documentation in a metropolitan hospital: impact on diagnostic\u2010related groups and <scp>W<\/scp>eighted <scp>I<\/scp>nlier <scp>E<\/scp>quivalent <scp>S<\/scp>eparation"],"prefix":"10.1111","volume":"43","author":[{"given":"N.","family":"Chin","sequence":"first","affiliation":[{"name":"Department of Medicine Maroondah Hospital Eastern Health"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"P.","family":"Perera","sequence":"additional","affiliation":[{"name":"Department of Medicine Maroondah Hospital Eastern Health"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"A.","family":"Roberts","sequence":"additional","affiliation":[{"name":"Department of Health Information Services Maroondah Hospital Eastern Health"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"R.","family":"Nagappan","sequence":"additional","affiliation":[{"name":"Department of Medicine Maroondah Hospital Eastern Health"},{"name":"Faculty of Medicine Monash University  Melbourne Victoria Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2013,7,11]]},"reference":[{"key":"e_1_2_6_2_1","doi-asserted-by":"publisher","DOI":"10.1177\/183335830903800105"},{"key":"e_1_2_6_3_1","volume-title":"Casemix Funding in Victoria","author":"Department of Human Services Victoria","year":"2008"},{"key":"e_1_2_6_4_1","doi-asserted-by":"publisher","DOI":"10.1071\/AH020072"},{"key":"e_1_2_6_5_1","volume-title":"Health Information Management Program. 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