Pascoe Shane W, Neal Richard D, Heywood Philip L, Allgar Victoria L, Miles Jeremy Nv, Stefoski-Mikeljevic Jasmina
Centre for Primary Health Care and Equity, University of New South Wales, Sydney 2052, Australia.
Fam Pract. 2008 Aug;25(4):215-20. doi: 10.1093/fampra/cmn023. Epub 2008 Jun 12.
The medical records of patients with cancer need to accurately record diagnoses for professionals to provide quality care. Aims. (i) To develop a methodology which identifies medical records of patients with a cancer diagnosis. (ii) To describe the effectiveness of search strategies to identify all patients in primary care with a cancer diagnosis compared with a diagnosis identified by a Cancer Registry.
The design of the study was a retrospective analysis of primary care medical records. Five general practices were recruited in the UK. The completeness and correctness of searches were measured and compared both within the practices and compared with a diagnosis identified by a Cancer Registry.
One in five of all primary care patients with cancer was not identified when a search for all patients with cancer was conducted using electronic codes for malignancy. One in five patient records with an electronic code for a malignancy that was confirmed by registration with the Cancer Registry actually lacked the necessary documentation to verify the cancer type, date of diagnosis or any other aspect of the malignant condition. Overall, electronic codes for cancer in these medical records have a poor level of completeness (29.4%) and correctness (65.6%) when compared with the Cancer Registry.
The electronic codes in five general practices were not able to identify all patients on the practice lists with a cancer diagnosis. Practices will only be able to comply with guidelines and meet quality targets if they can identify all of their current patients with a cancer diagnosis and will require information from a Cancer Registry in order to do this.
癌症患者的病历需要准确记录诊断信息，以便专业人员提供高质量的护理。目的：（i）开发一种识别癌症诊断患者病历的方法。（ii）描述与癌症登记处确定的诊断相比，在初级保健中识别所有癌症诊断患者的搜索策略的有效性。
该研究的设计是对初级保健病历进行回顾性分析。在英国招募了五家全科诊所。测量并比较了诊所内部搜索的完整性和正确性，并与癌症登记处确定的诊断进行了比较。
当使用恶性肿瘤电子编码搜索所有癌症患者时，五分之一的初级保健癌症患者未被识别。在癌症登记处登记确认的有恶性肿瘤电子编码的患者记录中，五分之一实际上缺乏核实癌症类型、诊断日期或恶性疾病任何其他方面的必要文件。总体而言，与癌症登记处相比，这些病历中的癌症电子编码完整性水平较低（29.4%），正确性水平较低（65.6%）。
五家全科诊所的电子编码无法识别诊所名单上所有患有癌症诊断的患者。只有当诊所能够识别所有当前患有癌症诊断的患者，并为此需要癌症登记处的信息时，诊所才能遵守指南并达到质量目标。
