Over the past decades, many high-level health care managers and planners in each country try to find the effective factors to the quality of treatment and their impact and selected the motto of " improving quality health care by improving the quality of information" from the their main goals. The health institutions should consistently apply Quality control (QC) to assess the quality of health care continuously. The patient's medical record is the first and most important source of collected information, because each record contains enough data to identify the full special patient, registered health issues and record any treatments [1]. All health care plans are performed based on illness data [2]. This subject is possible only using the exact classification of diseases and related law performance. The use of patient information will only be possible when they are properly organized and categorized. This is performed by coding of the diagnosis and treatment [3]. Coding is a related factor to the quality that is possible by coding medical records and …show more content…
Among the 250 records that mentioned primary procedures, 94.2% had procedure code. Besides, among the 173 records that mentioned the other procedures, 86.13% had code and 13.78 % of records had no code though they listed other procedures (Table1).
Also results showed that among 232 records in which primary diagnosis had code, 84.91 % of them were correct and coding 15.09% primary diagnosis had no adequate health codes. Also among the 101 records that mentioned the other diagnosis, 88.1% were correct and among the 231 records that coded primary procedure, 91.34% had correct code and also among the 149 records that coded the other procedures, 92.61% were correct and 7.39 % of other procedure codes were not correct (Table 2).