Department of Orthopaedics, Trafford General Hospital, Urmston, Greater Manchester, United Kingdom.
Injury. 2009 Jul;40(7):738-41. doi: 10.1016/j.injury.2008.11.018. Epub 2009 Apr 17.
In our hospital all operative procedures are coded using the OPCS 4.3 classification and in addition are entered into an independent theatre databases. Using these two databases we identified patients undergoing hip fracture surgery at this hospital between 1st November 2003 and 30th November 2006. We identified 408 cases. No single database identified all 408 cases. A quarter of cases (N=98) were not procedurally coded. Only 43.2% (N=176) of cases were recorded in both the theatre database and procedurally coded at the time of this study. Overall the coding accuracy of these 176 cases was 93.8%. Clinical coding at this hospital was unreliable and inaccurate, which has major implications for national statistics, performance analysis and most importantly Payment by Results. We discuss this further and offer possible solutions to improve the coding process.
在我们医院，所有手术操作都使用 OPCS 4.3 分类进行编码，并输入到一个独立的手术室数据库中。使用这两个数据库，我们确定了 2003 年 11 月 1 日至 2006 年 11 月 30 日在本院接受髋部骨折手术的患者。我们确定了 408 例。没有一个数据库能够识别出所有的 408 例患者。四分之一的病例（N=98）没有进行手术编码。只有 43.2%（N=176）的病例在本次研究时同时记录在手术室数据库和手术编码中。总的来说，这 176 例病例的编码准确率为 93.8%。该院的临床编码不可靠且不准确，这对国家统计数据、绩效分析以及最重要的按结果付费有重大影响。我们进一步讨论了这个问题，并提出了一些可能的解决方案来改进编码过程。
