Assessment of Clinical Coding Competency and Medical Terminology Proficiency among Health Information Management Professionals in Tertiary Hospitals, Bayelsa State

Abstract

Health Information Management (HIM) professionals need to be proficient in medical terminology and have clinical coding skills to ensure that health records are accurate, health statistics are reliable, disease surveillance is effective, reimbursement is accurate, and evidence-based healthcare is used for decision making. However, there is little empirical evidence about these competences among tertiary hospitals in the HIM professionals in Bayelsa State, Nigeria. The objectives of the study were to find out the clinical coding competency and medical terminologies knowledge of Health Information Management in Tertiary Hospitals of Bayelsa State. Descriptive - cross sectional design was adopted. Census sampling technique was used with all the 98 Health Information Management workers of the selected tertiary hospitals studied. A structured and validated questionnaire was used to collect data. The objectives were analyzed using descriptive statistics (frequency, percentage, mean and standard deviation) and the hypotheses were tested at 0.05 level of significance by the Pearson Product Moment Correlation and Independent Samples t-test. The results showed that the medical terminology skills were above average (Grand Mean = 3.38) and the clinical coding skills were above average (Grand Mean = 3.38). Continuous professional development, knowledge of medical terminology, professional experience, quality clinical documentation and access to coding resources had a significant impact on the coding competency (Grand Mean = 3.44). A high positive correlation was found between medical terminology knowledge and clinical coding competency (r = 0.684, p < 0.05). Coding competency was also highly correlated with professional experience (r = 0.491, p<0.05), and those who had received extra coding training reported significantly higher coding competency than those who had not received any training (t(96) =6.35, p<0.05). The study emphasizes the need for strengthening of continuous professional education, access to new coding resources and quality clinical documentation to further enhance clinical coding competency and health information quality in tertiary hospitals.