Background: The main data basis for the Diagnosis-Related Group (DRG) payment methodology is the disease diagnosis and clinical codes in the Medical Record (MR). Problems such as up-coding have arisen during implementation in many countries, and problems with MR quality and solutions have been studied mostly from the physician’s perspective. We investigated and analyzed the main influences on clinical coding from the perspectives of directors and coders in Medical Records Section (MRS) to provide recommendations for improvements in data quality. Methods: The questionnaire was developed, revised and improved using literature research and expert consultation methods. From 13 to 19 June 2024, the electronic questionnaire survey was conducted among the directors and coders of medical records department in healthcare organization. A total of 484 directors and coders were included in this study. And relevant statistics were computed and analyzed by non-parametric tests. Results: Coders should possess strong job responsibilities (92.36%), coding skills (91.33%), knowledge of clinical medicine (90.70%), and other comprehensive qualities and abilities. When encountering difficult problems, the clinical coders should first communicate with clinical doctors (91.95%). The two main factors affecting the quality of MR and clinical coding are the individual factors of doctors (88.84%) and the individual factors of coders (85.54%). Conclusions: Doctors and coders are the primary factors influencing the quality of clinical coding. It is recommended to establish a systematic training program for doctors to enhance the connotative quality of MR, for coders to solidify professional coding skills, strengthen communication and exchange, adopt reasonable behaviors, avoid moral hazards, and effectively improve the quality of clinical coding.

Background: The main data basis for the Diagnosis-Related Group(DRG) payment methodology is the disease diagnosis and clinical codes in the Medical Record(MR) . Problems such as up-coding have arisen during implementation in many countries, and problems with MR quality and solutions have been studied mostly from the physician's perspective. We investigated and analyzed the main influences on clinical coding from the perspectives of directors and coders in Medical Records Section(MRS) to provide recommendations for improvements in data quality. Methods: The questionnaire was developed, revised and improved using literature research and expert consultation methods. From June 13th to June 19th, 2024, the electronic questionnaire survey was conducted among the directors and coders of medical records department in healthcare organization. A total of 484 directors and coders were included in this study. And relevant statistics were computed and analyzed by non-parametric tests. Results: The results showed that the male-to-female ratio is about 1:2, and the ratio of MRS directors to coders is about 1:3. The highest proportion of bachelor's degree is 65.3%, with 29.5% having a major in Health Information Management(HIM), and 70.7% holding junior and intermediate professional titles. Coders should possess strong job responsibilities (92.36%), coding skills (91.33%), knowledge of clinical medicine(90.70%), and other comprehensive qualities and abilities. When encountering difficult problems, the clinical coders should first communicate with clinical doctors (91.95%). The two main factors affecting the quality of MR and clinical coding are the individual factors of doctors (88.84%) and the individual factors of coders (85.54%). Conclusions: Doctors and coders are the primary factors influencing the quality of clinical coding. It is recommended to establish a systematic training program for doctors to enhance the connotative quality of MR, for coders to solidify professional coding skills, strengthen communication and exchange, adopt reasonable behaviors, avoid moral hazards, and effectively improve the quality of clinical coding.

BACKGROUND Trusted paperless electronic medical record (TPEMR) management system serves as critical infrastructure for hospital governance and compliance under the National Health Commission’s Electronic Medical Record System Application Level Grading Evaluation (CN-EMR Grading) framework in China. Understanding user experience (UX) with system usability, trust, and sustained engagement may improve the accessibility, acceptability, and sustained adoption of the administrative health information system. OBJECTIVE The aim of this study was to use the Technology Acceptance Model (TAM) as a framework for qualitatively describing the UX, use behaviors, intent to use and intent to continue using among medical record administrators. METHODS We conducted a descriptive qualitative study guided by the extended Technology Acceptance Model (TAM) in a tertiary hospital achieving CN-EMR Grade 5. Through semi-structured interviews and focus groups with medical record administrators (n=23) and information system–related personnel (n=5), we examined perceived usefulness (PU), perceived ease of use (PEOU), intent to use and intent to continue using by a trained coder. To enhance analytic rigor and credibility, the coder met weekly with the principal investigator to review coding decisions, resolve ambiguities, and ensure that interpretations remained grounded in the data. RESULTS Participants acknowledged TPEMR's routine efficiency in retrieval, batch printing, and compliance reporting. However, exception-handling workflows triggered significant usability breakdowns. "Surface usability, deep complexity" emerged as a core pattern: standardized tasks felt intuitive, while deviations required opaque, multi-step workarounds across departments. Recurrent system instabilities and non-actionable error messages eroded psychological trust, fostering defensive behaviors like manual tracking despite mandatory use policies. CONCLUSIONS TPEMR optimization must move beyond happy-path efficiency to address exception-path resilience. Embedding visible compliance mechanisms, streamlining cross-departmental coordination, and providing transparent error recovery pathways are critical to converting mandated use into genuine, sustainable engagement among medical record administrators.