Wood V A, Wade D T, Hewer R L, Campbell M J
Frenchay Hospital, Bristol, UK.
J Neurol Neurosurg Psychiatry. 1989 Apr;52(4):449-58. doi: 10.1136/jnnp.52.4.449.
Effective planning and evaluation of medical services is only possible if appropriate and reliable information is available. Diagnoses of patients seen are essential data. The epidemiological value of standard, reliable diagnostic data could also be considerable. The International Classification of Diseases (ICD) is the only system currently available which provides a common basis of classification for general statistical use. A booklet, using ICD codes, for classifying in-patients and out-patients seen by neurologists has been developed. It is simple and easy to use, affords the necessary economy of time, and should result in uniformity of coding. Reliability studies confirm that inaccuracies occur when patients' diagnoses are coded retrospectively from their medical files, even when observers are medically trained. It is recommended that doctors should accept personal responsibility for coding patients' diagnoses at the time of consultation or discharge from hospital.
只有在具备适当且可靠的信息时,才有可能对医疗服务进行有效的规划和评估。所诊治患者的诊断是至关重要的数据。标准、可靠的诊断数据在流行病学方面的价值也可能相当可观。《国际疾病分类》(ICD)是目前唯一可用于一般统计用途的通用分类系统。现已编制了一本使用ICD编码对神经科医生诊治的住院患者和门诊患者进行分类的手册。它简单易用,能节省必要的时间,并且应能实现编码的一致性。可靠性研究证实,即使观察者具有医学专业培训,从患者病历中对患者诊断进行回顾性编码时仍会出现不准确情况。建议医生在会诊时或患者出院时对患者诊断编码承担个人责任。