Jakob J, Marenda D, Sold M, Schlüter M, Post S, Kienle P
Chirurgische Klinik, Universitätsmedizin Mannheim, Th.-Kutzer-Ufer 1-3, 68137, Mannheim, Deutschland,
Chirurg. 2014 Aug;85(8):705-10. doi: 10.1007/s00104-013-2696-4.
Complications after cholecystectomy are continuously documented in a nationwide database in Germany. Recent studies demonstrated a lack of reliability of these data. The aim of the study was to evaluate the impact of a control algorithm on documentation quality and the use of routine diagnosis coding as an additional validation instrument.
Completeness and correctness of the documentation of complications after cholecystectomy was compared over a time interval of 12 months before and after implementation of an algorithm for faster and more accurate documentation. Furthermore, the coding of all diagnoses was screened to identify intraoperative and postoperative complications.
The sensitivity of the documentation for complications improved from 46 % to 70 % (p = 0.05, specificity 98 % in both time intervals). A prolonged time interval of more than 6 weeks between patient discharge and documentation was associated with inferior data quality (incorrect documentation in 1.5 % versus 15 %, p < 0.05). The rate of case documentation within the 6 weeks after hospital discharge was clearly improved after implementation of the control algorithm. Sensitivity and specificity of screening for complications by evaluating routine diagnoses coding were 70 % and 85 %, respectively. The quality of documentation was improved by implementation of a simple memory algorithm.
德国一个全国性数据库持续记录胆囊切除术后的并发症情况。近期研究表明这些数据缺乏可靠性。本研究的目的是评估一种控制算法对文档质量的影响以及将常规诊断编码用作额外验证工具的情况。
在实施一种用于更快、更准确记录的算法之前和之后的12个月时间间隔内，比较胆囊切除术后并发症记录的完整性和正确性。此外，对所有诊断编码进行筛查以识别术中及术后并发症。
并发症记录的敏感性从46%提高到70%（p = 0.05，两个时间间隔内特异性均为98%）。患者出院与记录之间超过6周的较长时间间隔与较差的数据质量相关（错误记录分别为1.5%和15%，p < 0.05）。实施控制算法后，出院后6周内的病例记录率明显提高。通过评估常规诊断编码筛查并发症的敏感性和特异性分别为70%和85%。通过实施一个简单的记忆算法，文档质量得到了改善。
