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越南医院记录中伤害数据的质量。

The quality of injury data from hospital records in Vietnam.

机构信息

Centre for Injury Policy and Prevention Studies, Hanoi School of Public Health, Hanoi, Vietnam.

出版信息

Health Inf Manag. 2009;38(1):15-21. doi: 10.1177/183335830903800103.

Abstract

The objective of this research was to examine the level of agreement of coders for ICD-10 coding of injury discharges in Danang General Hospital in Vietnam. Two hundred and five medical records of children hospitalised in this facility due to injury were randomly selected and recoded. Information from medical records abstracted by two trained staff was recoded by external coders in Hanoi and in Australia, using ICD-10. The completeness and detail of external cause of injury recorded in medical records was poor. Agreement between coders for injury coding was average, with 32% to 40% discrepancy in the main diagnosis codes at three character level, and 57% to 60% discrepancy at four character level, depending on which coders were being compared. It was concluded that as hospital data represent a cost-effective source of information regarding injuries, with significant costs incurred in collecting such information through special studies and censuses (especially for a developing country such as Vietnam), it is important to establish the quality and value of hospital data for injury surveillance and prevention research and to explore ways in which these data can be improved.

摘要

本研究旨在检验越南岘港综合医院伤害出院 ICD-10 编码员之间的一致性。随机选择了该机构因伤害住院的 205 份病历,并对其进行重新编码。由两名经过培训的工作人员从病历中提取的信息由河内和澳大利亚的外部编码员使用 ICD-10 进行重新编码。记录在病历中的伤害外部原因完整性和详细程度较差。伤害编码员之间的一致性一般,主要诊断编码在三位字符水平上有 32%至 40%的差异,在四位字符水平上有 57%至 60%的差异,具体取决于正在比较的编码员。结论认为,由于医院数据是有关伤害的具有成本效益的信息来源,通过专门研究和普查收集此类信息会产生巨大成本(尤其是对于越南等发展中国家而言),因此,对于伤害监测和预防研究而言,重要的是要确定医院数据的质量和价值,并探索可以改进这些数据的方法。

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