McKenzie Kirsten, Harding Leith Forbes, Walker Susan Mary, Harrison James Edward, Enraght-Moony Emma Louise, Waller Garry Stewart
National Centre for Classification in Health, Queensland University of Technology, Queensland.
Aust N Z J Public Health. 2006 Dec;30(6):509-13. doi: 10.1111/j.1467-842x.2006.tb00777.x.
This research identifies the level of specificity of cause-of-injury morbidity data in Australia. The research explores reasons for poor-quality data across different causes-of-injury areas, including a lack of clinical documentation and insufficient detail in the classification system.
The 2002/03 hospital morbidity dataset of 593,079 injury-related hospital admissions was analysed to examine the specificity of coded external cause-of-injury data.
While overall specificity appeared high, the cause of 47,660 injuries was not specifically defined according to the code assigned. Only 56% of cases for whom injury was the result of an accidental fall were assigned a specific code to identify the causal detail; 19% were assigned an 'Other Specified' fall code, suggesting a lack of specific code availability; and 25% were assigned an 'Unspecified Fall' code, suggesting a lack of clinical documentation to facilitate code selection.
To improve the quality of injury-related hospital morbidity data, two main areas to focus resources are: 1) the development of more specific cause-of-injury codes; and 2) the provision of more detailed documentation from clinicians.
Clinicians and clinical coders need to work together to improve the quality of injury-related coded data through the provision of specific codes and improved clinical documentation. Accurate and comprehensive data pertaining to the circumstances surrounding hospitalised injury events will benefit injury prevention and surveillance initiatives, provide justification for resources related to injury hospitalisation, and assist in external cause research in Australia.
本研究确定了澳大利亚伤害发病原因数据的特异性水平。该研究探讨了不同伤害原因领域数据质量差的原因，包括临床记录缺失和分类系统细节不足。
分析了2002/03年593,079例与伤害相关的住院病例的医院发病数据集，以检查编码的外部伤害原因数据的特异性。
虽然总体特异性似乎较高，但47,660例伤害的原因未根据所分配的代码具体界定。意外伤害跌倒导致伤害的病例中，只有56%被分配了特定代码以识别因果细节；19%被分配了“其他特定”跌倒代码，表明缺乏可用的特定代码；25%被分配了“未指定跌倒”代码，表明缺乏临床记录以方便代码选择。
为提高与伤害相关的医院发病数据质量，需要集中资源的两个主要领域是：1）制定更具体的伤害原因代码；2）临床医生提供更详细的记录。
临床医生和临床编码人员需要共同努力，通过提供特定代码和改进临床记录来提高与伤害相关的编码数据质量。与住院伤害事件相关情况的准确和全面数据将有利于伤害预防和监测举措，为与伤害住院相关的资源提供依据，并有助于澳大利亚的外部原因研究。
