Assessment of ICD-10 Coding and Discharge Summary Documentation in public sector hospitals in the National Health Insurance Pilot Districts, South Africa
1
Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa
2
School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa, University of Cape Town, Cape Town, South Africa
3
Division of Health Systems and Public Health, Stellenbosch University, Cape Town, South Africa, Stellenbosch University, Cape Town, South Africa
Popul. Med. 2026;8(Supplement Supplement 1):A1773
ABSTRACT
BACKGROUND:
Accurate ICD‑10 coding and complete discharge summaries are essential for a strong health information system that supports health‑system strengthening and NHI implementation. High‑quality clinical data enables continuity of care, surveillance, planning, and resource allocation, yet coding quality remains inconsistent across South Africa’s public hospitals.
OBJECTIVE:
To assess the availability, completeness, and quality of ICD 10 coded diagnoses and discharge summaries in inpatient records across public hospitals in the 10 NHI pilot districts.
METHODS:
A retrospective cross-sectional review of 5,697 inpatient records was conducted in 44 public hospitals across all nine provinces. Data were extracted on the presence of a diagnosis, ICD-10 coding, and discharge summaries. Codes in the South African ICD-10 Master Industry Table (SA-MIT) were considered valid for use. Descriptive statistics and chi-square tests were used to compare results across provinces, hospital types, and departments.
RESULTS:
A diagnosis was recorded in 79.8% of folders and 66.3% included discharge summaries, yet only 15.4% had ICD 10 codes and just 10.9% had both a coded diagnosis and a summary. Coding completeness varied widely, with the Western Cape performing best (61.7% coding; 92% summaries) and some provinces recording no ICD 10 codes. Departmental rates ranged from 21.1% in paediatrics to 8.9% in obstetrics/gynaecology. Of 966 reviewed codes, 82.1% were valid, but 35.4% were unspecified (.9), reflecting low specificity. Common problems included insufficient clinical detail, illegible handwriting, and frequent typographical errors.
CONCLUSIONS:
ICD‑10 coding and discharge summaries in South African public hospitals show reasonable quality but remain insufficiently available, limiting their usefulness for surveillance, planning, and continuity of care. Strengthening NHI readiness will require fostering a stronger coding culture through standardised documentation, targeted training, and improved health information systems, alongside capacity building, digital integration, and enforcement of policies that enhance coding quality and support evidence‑based planning.
Accurate ICD‑10 coding and complete discharge summaries are essential for a strong health information system that supports health‑system strengthening and NHI implementation. High‑quality clinical data enables continuity of care, surveillance, planning, and resource allocation, yet coding quality remains inconsistent across South Africa’s public hospitals.
OBJECTIVE:
To assess the availability, completeness, and quality of ICD 10 coded diagnoses and discharge summaries in inpatient records across public hospitals in the 10 NHI pilot districts.
METHODS:
A retrospective cross-sectional review of 5,697 inpatient records was conducted in 44 public hospitals across all nine provinces. Data were extracted on the presence of a diagnosis, ICD-10 coding, and discharge summaries. Codes in the South African ICD-10 Master Industry Table (SA-MIT) were considered valid for use. Descriptive statistics and chi-square tests were used to compare results across provinces, hospital types, and departments.
RESULTS:
A diagnosis was recorded in 79.8% of folders and 66.3% included discharge summaries, yet only 15.4% had ICD 10 codes and just 10.9% had both a coded diagnosis and a summary. Coding completeness varied widely, with the Western Cape performing best (61.7% coding; 92% summaries) and some provinces recording no ICD 10 codes. Departmental rates ranged from 21.1% in paediatrics to 8.9% in obstetrics/gynaecology. Of 966 reviewed codes, 82.1% were valid, but 35.4% were unspecified (.9), reflecting low specificity. Common problems included insufficient clinical detail, illegible handwriting, and frequent typographical errors.
CONCLUSIONS:
ICD‑10 coding and discharge summaries in South African public hospitals show reasonable quality but remain insufficiently available, limiting their usefulness for surveillance, planning, and continuity of care. Strengthening NHI readiness will require fostering a stronger coding culture through standardised documentation, targeted training, and improved health information systems, alongside capacity building, digital integration, and enforcement of policies that enhance coding quality and support evidence‑based planning.
| eISSN: | 2654-1459 |
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