{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T21:58:48Z","timestamp":1777672728685,"version":"3.51.4"},"reference-count":18,"publisher":"SAGE Publications","issue":"1","license":[{"start":{"date-parts":[[2014,3,1]],"date-time":"2014-03-01T00:00:00Z","timestamp":1393632000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["HIM J"],"published-print":{"date-parts":[[2014,3]]},"abstract":"<jats:p>This paper reviews the documentation and coding of External causes of admitted fall cases in a major hospital. Intensive analysis of a random selection of 100 medical records included blind re-coding in the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian Modification (ICD-10-AM), Fifth Edition for External causes to ascertain whether: (i) the medical records contained sufficient information for assignment of specific External cause codes; and (ii) the most appropriate External cause codes were assigned per available documentation. Comparison of the hospital data with the state-wide Victorian Admitted Episodes Database (VAED) data on frequency of use of External cause codes revealed that the index hospital, a major trauma centre, treated comparatively more falls involving steps, stairs and ladders. The hospital sample reflected lower usage, than state-wide, of unspecified External cause codes and Other specified activity codes; otherwise, there was similarity in External cause coding. A comparison of researcher and hospital codes for the falls study sample revealed differences. The ambulance report was identified as the best source of External cause information; only 50% of hospital medical records contained sufficient information for specific code assignation for all three External cause codes, mechanism of injury, place of occurrence and activity at time of injury. Whilst all medical records contained mechanism of falls injury information, 16% contained insufficient details, indicating a deficiency in medical record documentation to underpin external cause coding. This was compounded by flaws in the ICD- 10-AM classification.<\/jats:p>","DOI":"10.1177\/183335831404300102","type":"journal-article","created":{"date-parts":[[2016,3,10]],"date-time":"2016-03-10T06:00:50Z","timestamp":1457589650000},"page":"6-15","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["The Quality of Medical Record Documentation and\n                    <i>External Cause<\/i>\n                    of Fall Injury Coding in a Tertiary Teaching Hospital"],"prefix":"10.1177","volume":"43","author":[{"given":"Janet","family":"Cunningham","sequence":"first","affiliation":[{"name":"Janet Cunningham, BHlthInfoMangt(Hons), Health Information Advisor, Admitted Emergency and Elective Data, Department of Health, Melbourne, Victoria, 3000, AUSTRALIA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dianne","family":"Williamson","sequence":"additional","affiliation":[{"name":"Dianne Williamson, BAppSc(MRA), GradDipErg, Senior Lecturer, Department of Health Information Management, School of Public Health & Human Biosciences, Faculty of Health Sciences, La Trobe University, Bundoora VIC 3086, AUSTRALIA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kerin M.","family":"Robinson","sequence":"additional","affiliation":[{"name":"Kerin M. Robinson, BHA, BAppSc(MRA), MHP, CHIM, Head, Department of Health Information Management, School of Public Health & Human Biosciences, Faculty of Health Sciences, La Trobe University, Bundoora VIC 3086, AUSTRALIA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rhonda","family":"Carroll","sequence":"additional","affiliation":[{"name":"Rhonda Carroll, RMRL, Director Information and Performance, Melbourne Health, Victoria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ross","family":"Buchanan","sequence":"additional","affiliation":[{"name":"Ross Buchanan, BMedRecAdmin(Hons), MHSc(HlthAdmin), Director, Health Information Services, Information Development Division, Alfred Health, Melbourne VIC 3004"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lindsay","family":"Paul","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2014,3,1]]},"reference":[{"key":"bibr1-183335831404300102","volume-title":"Injury research and statistics series number 70. 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[Available at: http:\/\/onlinelibrary.wiley.com\/doi\/10.1111\/imj.12084\/abstract (accessed 5 May 2013). Details of hard copy publication not available at time of writing].","DOI":"10.1111\/imj.12084"},{"key":"bibr6-183335831404300102","doi-asserted-by":"publisher","DOI":"10.1177\/183335831304200303"},{"key":"bibr7-183335831404300102","doi-asserted-by":"publisher","DOI":"10.1177\/183335830903800103"},{"key":"bibr8-183335831404300102","doi-asserted-by":"publisher","DOI":"10.1136\/ip.7.4.334"},{"key":"bibr9-183335831404300102","doi-asserted-by":"publisher","DOI":"10.1016\/j.aap.2007.09.008"},{"key":"bibr10-183335831404300102","doi-asserted-by":"publisher","DOI":"10.1136\/ip.2008.020479"},{"key":"bibr11-183335831404300102","volume-title":"The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification","author":"National Centre for Classification in Health","year":"2008","edition":"6"},{"key":"bibr12-183335831404300102","volume-title":"Performance Indicators for Coding Quality (PICQ) 2008: User guide","author":"National Centre for Classification in Health","year":"2008"},{"key":"bibr13-183335831404300102","volume-title":"The good clinical documentation guide","author":"National Centre for Classification in Health","year":"2003"},{"key":"bibr14-183335831404300102","volume-title":"Introduction to research in the health sciences","author":"Polgar S.","year":"2000","edition":"4"},{"key":"bibr15-183335831404300102","doi-asserted-by":"publisher","DOI":"10.1177\/183335831104000103"},{"key":"bibr16-183335831404300102","volume-title":"Paper presented at the 2010","author":"Shepheard J.","year":"2010"},{"key":"bibr17-183335831404300102","doi-asserted-by":"publisher","DOI":"10.1177\/183335830903800104"},{"key":"bibr18-183335831404300102","volume-title":"Your hospitals: A report on Victoria's public hospitals July 2007 to June 2008","author":"Victorian Government, Department of Human Services","year":"2008"}],"container-title":["Health Information Management Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/183335831404300102","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/183335831404300102","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T08:05:55Z","timestamp":1777449955000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/183335831404300102"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2014,3]]},"references-count":18,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2014,3]]}},"alternative-id":["10.1177\/183335831404300102"],"URL":"https:\/\/doi.org\/10.1177\/183335831404300102","relation":{},"ISSN":["1833-3583","1833-3575"],"issn-type":[{"value":"1833-3583","type":"print"},{"value":"1833-3575","type":"electronic"}],"subject":[],"published":{"date-parts":[[2014,3]]}}}