McKenzie Kirsten, Enraght-Moony Emma, Harding Leith, Walker Sue, Waller Garry, Chen Linping
National Centre for Classification in Health, School of Public Health and Institute for Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Qld. 4059, Australia.
Accid Anal Prev. 2008 Mar;40(2):714-8. doi: 10.1016/j.aap.2007.09.008. Epub 2007 Oct 2.
Complete and accurate information about hospitalised injuries is essential for injury risk and outcome research, though the accuracy and reliability of hospital data for injury surveillance are often questioned. To ascertain clinical coders' views of the reasons for a lack of specificity in external cause code usage and ways to improve external cause coding, a nationwide survey of coders was conducted in Australia in 2006. Four hundred and two coders participated in the questionnaire. The results of this study show that discharge summaries and doctors' notes were the poorest source of information regarding external causes, place of injury occurrence, and activity at the time of injury. Coders viewed missing external cause information and missing documentation as having the greatest impact on the quality of external cause coding. A large majority of coders suggested that improving clinical documentation in the emergency department and introducing a centralised structured form for external cause information would improve the quality of external cause coding. Clinical coders are a valuable source of information regarding problems with, and solutions to the collection of high quality data and this research has highlighted several areas where improvements can be made and further research is needed.
对于伤害风险和结果研究而言，完整准确的住院伤害信息至关重要，尽管用于伤害监测的医院数据的准确性和可靠性常常受到质疑。为了确定临床编码人员对于外部原因编码使用缺乏特异性的原因以及改进外部原因编码方法的看法，2006年在澳大利亚对编码人员进行了一项全国性调查。402名编码人员参与了问卷调查。这项研究的结果表明，出院小结和医生记录是关于外部原因、伤害发生地点以及伤害时活动情况的最不可靠信息来源。编码人员认为缺少外部原因信息和缺少文档对外部原因编码质量影响最大。绝大多数编码人员建议，改善急诊科的临床文档记录并引入用于外部原因信息的集中式结构化表格，将提高外部原因编码的质量。临床编码人员是有关高质量数据收集问题及解决方案的宝贵信息来源，并且这项研究突出了几个可以改进的领域以及需要进一步研究的方面。
