Surján G
Haynal University of Health Sciences, Management Information Department, Budapest, Hungary.
Int J Med Inform. 1999 May;54(2):77-95. doi: 10.1016/s1386-5056(98)00171-3.
International Classification of Diseases (ICD) codes are used for indexing medical diagnoses for various purposes and in various contexts. According to the literature and our personal experience, the validity of the coded information is unsatisfactory in general, however the 'correctness' is purpose and environment dependent. For detecting potential error sources, this paper gives a general framework of the coding process. The key elements of this framework are: (1) the formulation of the established diagnoses in medical language; (2) the induction from diagnoses to diseases; (3) indexing the diseases to ICD categories; (4) labelling of the coded entries (e.g. principal disease, complications, etc.). Each step is a potential source of errors. The most typical types of error are: (1) overlooking of diagnoses; (2) incorrect or skipped induction; (3) indexing errors; (4) violation of ICD rules and external regulations. The main reasons of the errors are the physician's errors in the primary documentation, the insufficient knowledge of the encoders (different steps of the coding process require different kind of knowledge), the internal inconsistency of the ICD, and some psychological factors. Computer systems can facilitate the coding process, but attention has to be paid to the entire coding process, not only to the indexing phase.
国际疾病分类（ICD）编码用于在各种目的和背景下对医学诊断进行索引。根据文献和我们的个人经验，编码信息的有效性总体上不尽人意，但其“正确性”取决于目的和环境。为了检测潜在的错误来源，本文给出了编码过程的一般框架。该框架的关键要素包括：（1）用医学语言表述既定诊断；（2）从诊断归纳到疾病；（3）将疾病索引到ICD类别；（4）对编码条目进行标注（例如主要疾病、并发症等）。每一步都是潜在的错误来源。最典型的错误类型有：（1）遗漏诊断；（2）归纳错误或遗漏；（3）索引错误；（4）违反ICD规则和外部规定。错误的主要原因包括医生在原始记录中的错误、编码人员知识不足（编码过程的不同步骤需要不同类型的知识）、ICD内部的不一致性以及一些心理因素。计算机系统可以促进编码过程，但必须关注整个编码过程，而不仅仅是索引阶段。
