Cunningham Janet, Williamson Dianne, Robinson Kerin M, Carroll Rhonda, Buchanan Ross, Paul Lindsay
Department of Health Melbourne, Victoria, Australia.
Department of Health Information Management School of Public Health & Human Biosciences Faculty of Health Sciences La Trobe University Bundoora VIC, AUSTRALIA.
Health Inf Manag. 2014;43(1):6-15. doi: 10.1177/183335831404300102.
This paper reviews the documentation and coding of External causes of admitted fall cases in a major hospital. Intensive analysis of a random selection of 100 medical records included blind re-coding in the International Statistical Classification of Diseases and Related Health Problems, Tenth revision, Australian Modification (ICD-10-AM), Fifth Edition for External causes to ascertain whether: (i) the medical records contained sufficient information for assignment of specific External cause codes; and (ii) the most appropriate External cause codes were assigned per available documentation. Comparison of the hospital data with the state-wide Victorian Admitted Episodes Database (VAED) data on frequency of use of External cause codes revealed that the index hospital, a major trauma centre, treated comparatively more falls involving steps, stairs and ladders. The hospital sample reflected lower usage, than state-wide, of unspecified External cause codes and Other specified activity codes; otherwise, there was similarity in External cause coding. A comparison of researcher and hospital codes for the falls study sample revealed differences. The ambulance report was identified as the best source of External cause information; only 50% of hospital medical records contained sufficient information for specific code assignation for all three External cause codes, mechanism of injury, place of occurrence and activity at time of injury. Whilst all medical records contained mechanism of falls injury information, 16% contained insufficient details, indicating a deficiency in medical record documentation to underpin external cause coding. This was compounded by flaws in the ICD-10-AM classification.
本文回顾了一家大型医院收治的跌倒病例的外部原因记录与编码情况。对随机抽取的100份病历进行深入分析，包括按照《疾病和相关健康问题国际统计分类，第十次修订版，澳大利亚修改版》（ICD - 10 - AM）第五版对外部原因进行盲态重新编码，以确定：（i）病历中是否包含足够信息来分配特定的外部原因编码；以及（ii）根据现有文档是否分配了最合适的外部原因编码。将医院数据与维多利亚州全州收治病例数据库（VAED）中关于外部原因编码使用频率的数据进行比较，结果显示，作为主要创伤中心的索引医院，治疗的涉及台阶、楼梯和梯子的跌倒病例相对较多。医院样本中未指定外部原因编码和其他特定活动编码的使用频率低于全州水平；否则，外部原因编码情况相似。对跌倒研究样本的研究者编码和医院编码进行比较，发现存在差异。救护车报告被确定为外部原因信息的最佳来源；只有50%的医院病历包含足够信息，可用于为所有三个外部原因编码（损伤机制、发生地点和受伤时的活动）分配特定编码。虽然所有病历都包含跌倒损伤机制信息，但16%的病历细节不足，这表明病历记录存在缺陷，无法为外部原因编码提供支持。ICD - 10 - AM分类中的缺陷使情况更加复杂。
