Massanari R M, Wilkerson K, Streed S A, Hierholzer W J
Am J Public Health. 1987 May;77(5):561-4. doi: 10.2105/ajph.77.5.561.
Proper reporting of discharge diagnoses, including complications of medical care, is essential for maximum recovery of revenues under the prospective reimbursement system. To evaluate the effectiveness of abstracting techniques in identifying nosocomial infections at discharge, discharge abstracts of patients with nosocomial infections were reviewed during September through November of 1984. Patients with nosocomial infections were identified using modified Centers for Disease Control (CDC) definitions and trained surveillance technicians. Records which did not include the diagnosis of nosocomial infections in the discharge abstract were identified, and potential lost revenues were estimated. We identified 631 infections in 498 patients. On average, only 57 per cent of the infections were properly recorded and coded in the discharge abstract. Of the additional monies which might be anticipated by the health care institution to assist in the cost of care of adverse events, approximately one-third would have been lost due to errors in coding in the discharge abstract. Although these lost revenues are substantial, they constitute but a small proportion of the potential costs to the institution when patients acquire nosocomial infections.
正确报告出院诊断，包括医疗护理并发症，对于在前瞻性报销系统下最大限度地收回收入至关重要。为了评估出院时识别医院感染的摘要技术的有效性，我们在1984年9月至11月期间审查了医院感染患者的出院摘要。使用美国疾病控制中心（CDC）修改后的定义和经过培训的监测技术人员来识别医院感染患者。识别出出院摘要中未包括医院感染诊断的记录，并估计潜在的收入损失。我们在498名患者中识别出631例感染。平均而言，出院摘要中仅正确记录并编码了57%的感染。医疗保健机构可能预期的用于协助不良事件护理费用的额外资金中，约有三分之一会因出院摘要编码错误而损失。尽管这些损失的收入数额巨大，但与患者发生医院感染时机构面临的潜在成本相比，仅占很小的比例。
