图表文件记录质量及其与行政出院记录有效性的关系。

Chart documentation quality and its relationship to the validity of administrative data discharge records.

机构信息

Centre for Health and Policy Studies, University of Calgary, Canada.

出版信息

Health Informatics J. 2010 Jun;16(2):101-13. doi: 10.1177/1460458210364784.

Abstract

The validity of administrative data may be vulnerable to how well physicians document medical charts. The objective of this study is to determine the relationship between chart documentation quality and the validity of administrative data. The charts for patients who underwent carotid endarterectomy were re-abstracted and rated for the quality of documentation. Poorly and well-documented charts were compared by patient, physician, and hospital variables, as well as on agreement between the administrative and re-abstracted data. Of the 2061 charts reviewed, 42.6 per cent were rated well documented. The proportion of charts well documented varied from 14.6 to 87.5 per cent across 17 hospitals, but did not vary significantly by patient characteristics. The kappa statistic was generally higher for well-documented charts than for poorly documented charts, but varied across comorbidities. In conclusion, poorly documented hospital charts tend to be translated into invalid administrative data, which reduces the communication of clinical information among healthcare providers.

摘要

行政数据的有效性可能容易受到医生记录医疗图表的情况影响。本研究旨在确定图表记录质量与行政数据有效性之间的关系。对接受颈动脉内膜切除术的患者的图表进行了重新摘录和记录质量评分。通过患者、医生和医院变量以及行政数据和重新摘录数据之间的一致性,比较了记录质量差和记录质量好的图表。在审查的 2061 份图表中,42.6%的图表被评为记录质量好。在 17 家医院中,记录质量好的图表比例从 14.6%到 87.5%不等,但患者特征差异不显著。在记录质量好的图表中,kappa 统计值通常高于记录质量差的图表,但在合并症方面存在差异。总之,记录质量差的医院图表往往会转化为无效的行政数据,从而减少了医疗保健提供者之间临床信息的交流。

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