Martínez Jiménez R, García Benavides F
Servicio Andaluz de Salud, Consejería de Salud y Consumo, Junta de Andalucía.
Med Clin (Barc). 1991 May 25;96(20):765-8.
The registry book of admission and discharges (RBD) is operative in most public and private hospitals of this country. Currently its reformation is contemplated, consisting in a modification of the minimal set of basic data and its computerization. The aim of the present study was to evaluate the accuracy of the discharge diagnosis recorded in the RBD and to analyze the possible factors implicated in the current quality level.
In a sample of 9 hospitals from the Seville province, 2,634 discharges were selected with a stratified sampling process which was proportional to the number of discharges in each stratum during 1985. The accuracy of the diagnosis recorded in the RBD was estimated by comparing it with that in the clinical record (CR).
The accuracy indexes showed that, for the large diagnostic groups, only in 45% of discharges the diagnosis coincided in both documents. The accuracy increased to 89% when the estimation was made after excluding those discharges where the diagnosis was not recorded in the RBD and/or in the CR (n = 1303).
The fulfillment of the RBD appears as the main error source, followed by the selection of the major diagnosis and its transcription in the different documents of the circuit. It is concluded that a precondition for the success of a reformed RBD is to guarantee the fulfillment of data.
入院与出院登记册（RBD）在该国大多数公立和私立医院中都在使用。目前正在考虑对其进行改革，包括修改基本数据的最小集并实现计算机化。本研究的目的是评估RBD中记录的出院诊断的准确性，并分析当前质量水平中可能涉及的因素。
在塞维利亚省的9家医院的样本中，通过分层抽样过程选择了2634例出院病例，该过程与1985年各层的出院病例数成比例。通过将RBD中记录的诊断与临床记录（CR）中的诊断进行比较，估计RBD中记录的诊断的准确性。
准确性指标显示，对于大型诊断组，只有45%的出院病例在两份文件中的诊断一致。在排除那些在RBD和/或CR中未记录诊断的出院病例（n = 1303）后进行估计时，准确性提高到89%。
RBD的填写似乎是主要的错误来源，其次是主要诊断的选择及其在流程不同文件中的转录。得出的结论是，改革后的RBD成功的一个前提是保证数据的填写。
