Park R H, McCabe P, Russell R I
Gastroenterology Unit, Royal Infirmary, Glasgow.
Health Bull (Edinb). 1992 Jan;50(1):24-8; discussion 29-31.
We have studied the accuracy of the hospital diagnostic data for Wilson's disease (WD) in Scotland. The computerised records of the Scottish Hospital In-Patient Statistics provided information on 41 patients, coded as having been discharged from hospital with a diagnosis of WD. Review of the patients' case notes revealed that 12 (29.6%) did not have WD, although half of these cases had 'query Wilson's disease' on the discharge summary or letter. In the other six cases, errors arose due to miscoding by the medical records staff.
我们研究了苏格兰医院关于威尔逊氏病(WD)诊断数据的准确性。苏格兰医院住院患者统计数据的计算机记录提供了41名患者的信息,这些患者被编码为因WD诊断而出院。查阅患者病历发现,12名患者(29.6%)没有患WD,尽管其中一半病例在出院小结或信件中有“疑似威尔逊氏病”的记录。在其他6个病例中,错误是由于病历工作人员编码错误导致的。