Ballaro A, Oliver S, Emberton M
The Institute of Urology and Nephrology, London, UK.
BJU Int. 2000 Mar;85(4):389-91. doi: 10.1046/j.1464-410x.2000.00471.x.
To determine the accuracy of routine data coding in a large multispeciality urological unit. Materials and methods From the clinical records, the diagnosis and procedure codes were ascribed to 106 finished consultant episodes (FCEs) in urology, by two urological trainees. The codes were compared with those ascribed by professional hospital coders (and of which the trainees were unaware) from information written on the audit form by junior medical staff. Where there were discrepancies in codes an error was recorded and the stage in the coding process in which it occurred was determined.
Forty-eight coding errors were found in 38 of the 106 (36%) FCEs; 34 (71%) were caused by inaccurate coding and 14 (29%) were the result of the incorrect completion of audit forms.
The clinical codes generated from the authors' department do not accurately reflect the clinical practice. If coding errors of this magnitude are typical of urology units in general, the concept of hospital performance tables (which will be generated using routine clinical data) is untenable unless data recording is given higher priority.
确定大型多专科泌尿外科科室常规数据编码的准确性。材料与方法 两名泌尿外科实习医生从临床记录中为106例泌尿外科会诊结束病例（FCE）确定诊断和手术编码。将这些编码与专业医院编码员（实习医生对此不知情）根据初级医务人员在审核表上填写的信息所确定的编码进行比较。若编码存在差异，则记录错误，并确定错误发生在编码过程的哪个阶段。
在106例FCE中的38例（36%）发现了48处编码错误；34处（71%）是由编码不准确导致的，14处（29%）是审核表填写错误所致。
作者所在科室生成的临床编码不能准确反映临床实践。如果这种程度的编码错误在一般泌尿外科科室中很典型，那么除非给予数据记录更高优先级，否则（将使用常规临床数据生成的）医院绩效表的概念是站不住脚的。
