James N K, Reid C D
Department of Plastic and Reconstructive Surgery, Frenchay Hospital, Bristol.
Br J Plast Surg. 1991 Jan;44(1):62-4. doi: 10.1016/0007-1226(91)90183-k.
The effective coding of data to produce a medical audit relies on agreement between the coders. This study was designed to assess whether coders can agree on codes for diagnosis and operations in a plastic surgery unit. Information from 50 patients was presented to a panel of six coders who were required to code the data using the International Classification of Diseases (ICD-9) and the Office of Population Census Studies (OPCS-4) systems. The results show that agreement between all the panellists occurred in only 32 out of 50 patients for one diagnostic code and 30 out of 50 for one operation code. When a patient had more than one diagnosis or operation, agreement was very much worse. Expert coders produced better results than the medical coders. The results are discussed with reference to other coding systems.
为进行医学审计而对数据进行有效编码，依赖于编码人员之间的一致性。本研究旨在评估编码人员在整形外科科室中对诊断和手术编码能否达成一致。50名患者的信息提供给了一个由6名编码人员组成的小组，要求他们使用国际疾病分类（ICD - 9）和人口普查研究办公室（OPCS - 4）系统对数据进行编码。结果显示，在50名患者中，所有小组成员对一个诊断编码仅在32例中达成一致，对一个手术编码仅在30例中达成一致。当一名患者有不止一个诊断或手术时，一致性要差得多。专家编码人员比医学编码人员得出的结果更好。将结合其他编码系统对结果进行讨论。
