Seeley Helen M
Academic Neurosurgery, Box 167, Addenbrooke's Hospital, Hills Road, Cambridge CB2 OQQ, UK.
Health Informatics J. 2007 Jun;13(2):135-53. doi: 10.1177/1460458207076469.
The aim of this article is to propose standards for data collection in head injury, the commonest cause of death and disability in young people. The objectives include evaluation of an audit methodology. The retrospective review conducted for the Eastern Head Injury Study in the UK identified a variety of problems, notably ambiguous terminology, inadequacies in ICD-10 codes, and inconsistent practices in recording data on head injury. Conclusions are that the standards developed through the review should improve data collection practice, and rehabilitation codes should assist in tracking patient pathways through care.
本文旨在提出针对头部损伤数据收集的标准，头部损伤是年轻人死亡和残疾的最常见原因。目标包括评估一种审计方法。对英国东部头部损伤研究进行的回顾性审查发现了各种问题，尤其是术语模糊、ICD - 10编码不足以及头部损伤数据记录做法不一致。结论是，通过审查制定的标准应能改善数据收集做法，康复编码应有助于追踪患者的护理路径。
