Coder Meeting Minutes
September 2016 2016-Sep-scenario
Coder Training Modules
If you would like access to these please contact Rosemary_Varga@URMC.Rochester.edu
Finger Lakes Region HELPER Guidelines
The attached is additions to the Guidelines for the New York State Certificate of Live Birth & Quality Improvement 2011. These additions were included after seeking increased clarifications from The NYSDOH Bureau of Vital Records Department and the Finger Lakes Region Primary Investigator.
This book is currently under re-construction.
What is a Coder?
Birthing hospitals are required to have a staff member who is certified with the New York State Department of Health and is trained to enter birth data into the Statewide Perinatal Data System. For infants born at home or at a non-birthing hospital parents work directly with their local Office of Vital Statistics to obtain birth certificates for their infants
Birth Coders, staff who code and enter birth data, are know by different names. Coders, Birth Registrars, and Birth Certificate Registrars to name a few.
Birth Certificate Process
The Birth Coder's job responsibilities include gathering information about the new mother's prenatal, intrapartum and delivery experience, as well as her immediate post-partum course and the infant's newborn experience until discharge or the 1st 5 days of life whichever is longer. In addition, the Coder collects information directly from all new mothers related to their experiences prenatally including information and materials gained from the prenatal care provider. Obtaining information from the new mother can be time consuming for the Coder as the new mothers are busy with their new infant and answering questions regarding their prenatal period is not a top priority. In addition to collecting the birth data the Coder assists the mother in obtaining a Social Security number for her infant and when appropriate she assists in the filing of an Acknowledgement of Paternity form if requested by those who are not married.
Over 350 data fields are collected on each birth to complete the birth certificate. These include fields required for all United States births by the Center for Disease Control and Prevention as well as additional New York State required fields.
Once the birth information is collected, the Coder enters the data into the Statewide Perinatal Data System (SPDS) after which she prints an abstraction of the entered data which is then attached to a Certificate of Live Birth and is then signed by the certifying / delivering provider. The Coder, then, sends the Certificate of Live Birth with any added forms to the Office of VItal Statistics. Six to eight weeks later the Office of Vital Statistics mails a formal Birth Certificate to the new parents.
Initial and Ongoing Training
New Coders are asked to complete seven (7) training modules which correspond to the different sections of the Birth Certicicate workbook as part of their orientation to the position of Birth Coder. These modules allow the new Birth Coders to self-study as they learn the basics of birth coding, requiring less of the hospital staff's time. The modules were created with input from the Data Coordinator, Coders, and the physician who oversees the Birth Certificate project for New York State.
Monthly "scenarios" serve as an ongoing training tool. They are distributed via email to all Birth Coders. These scenarios include a brief description of a coding "situation" and require the Coder to make a decision based on the information presented. This exercise requires little of the Coder's time and assures that everyone in the Finger Lakes Region is coding potentially unclear situations in a uniform manner.
Bi-monthly Coder Meetings are a combination of in-service training and staff meeting. They provide a forum where Birth Coders, who often work in isolation from other Birth Coders, can ask questions and discuss coding issues. All questions raised by the Region's Coders since the previous Coder Meeting are discussed. These meetings help Coders gain a better understanding of the fields they code while increasing their confidence in their decision making ability.
Faculty from the Regional Perinatal Center and guest speakers are asked to present information at Coder Meetings on topics related to their research using birth data or to some aspect of medical information that the Coders encounter (e.g. Birth Certificate infection fields). The outside presentations reinforce the valuable role played by the Birth Coders to our understanding of how to improve care and pregnancy outcomes.
Annually the Regional Perinatal Center (RPC) is required to meet with each Regional hospital's Obstetrics and Nursery / NICU personnel. This is generally lead by the Primary Investigator (from the RPC) and an attending NICU pediatrician. The previous years' birth statistics are reviewed and many of the transferred mothers and babies are discussed (transfers from the outlying hospital to the RPC). Changes and intended changes in care are, also, discussed.
The Data Coordinator is available, if needed , to answer questions on the coding of the data presented
The Birth Coders are encouraged to attend. As the Data Coordinator is required to make an annual "home" visit with the hospital's Coder, this is a perfect opportunity to combine the two. Several charts are re-coded with attention to details that are difficult to code so that if necessary, changes in practice can be encouraged and supported.
All training is directed toward increasing the accuracy, completeness and reliability of the data collected and entered into the Statewide System.
Acknowledgement of Paternity
A good resource for Coders and families -
Paternity establishment - What and Why
Instructions for Completing the Acknowledgement of Paternity