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评估创伤登记数据与医院记录的一致性。

Assessing the concordance of trauma registry data and hospital records.

作者信息

McKenzie Kirsten, Walker Sue, Besenyei Andrea, Aitken Leanne M, Allison Bridget

机构信息

National Centre for Classification in Health, School of Public Health, Queensland University of Technology, Victoria Park Road, Kelvin Grove, QLD 4059, Australia.

出版信息

Health Inf Manag. 2005;34(1):3-7. doi: 10.1177/183335830503400103.

Abstract

This study examined the concordance of trauma registry and hospital records in Queensland in 1998. The design involved a retrospective review of records and documentation comparison. Demographic variables from the registry were matched to hospital data to obtain admission/diagnoses data. There were four main types of error identified which included: failure to identify relevant patients, inappropriate inclusion of patients, insufficient/inaccurate data in hospital records, and insufficient/inaccurate data in the trauma registry. Of the 87 cases with data quality issues, 63% were due to Queensland Trauma Registry (QTR) data errors, 5% were due to hospital data errors, and in 32% of cases the source of errors was undetermined. Of the potential 1759 trauma cases from 1998, 12 cases should have been included in the registry that were not, 71 cases should not have been included in the registry, and 4 cases were removed from the study due to insufficient or inaccurate hospital record data. Overall, a concordance rate of approximately 95% was found between the trauma registry records and the hospital records.

摘要

本研究调查了1998年昆士兰州创伤登记处与医院记录之间的一致性。该研究设计包括对记录的回顾性审查和文档比较。将登记处的人口统计学变量与医院数据进行匹配,以获取入院/诊断数据。识别出四种主要类型的错误,包括:未能识别相关患者、不恰当地纳入患者、医院记录中的数据不足/不准确以及创伤登记处的数据不足/不准确。在87例存在数据质量问题的病例中,63%是由于昆士兰创伤登记处(QTR)的数据错误,5%是由于医院数据错误,32%的病例错误来源未确定。在1998年潜在的1759例创伤病例中,有12例本应纳入登记处但未被纳入,71例不应纳入登记处,4例因医院记录数据不足或不准确而被排除在研究之外。总体而言,创伤登记处记录与医院记录之间的一致性率约为95%。

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