48538Department of Emergency Medicine, University of Ulsan College of Medicine, Ulsan University Hospital, Dong-gu Ulsan, Korea.
Inquiry. 2022 Jan-Dec;59:469580221081433. doi: 10.1177/00469580221081433.
This study aimed to determine if applying International Classification of Diseases (ICD) disease codes directly as the cause of death (COD) on death certificates (DCs) instead of writing or typing the COD could reduce the use of garbage codes.
Beginning in April of 2016, a documentation process change was made, retiring the process of hand-writing or typing the COD onto DCs to directly applying ICD disease codes that were registered during the patient's course of treatment. The DCs issued at the emergency department (ED) 1 year before (Pre-code group) and after (Code group) applying ICD disease codes directly on DCs was instituted were retrospectively analyzed. The occurrence of garbage codes along with other major and minor errors was compared between the two groups. The investigation and judgment of errors were performed by four emergency physicians.
The overall garbage code occurrence in the Code group (25%) was significantly lower than that in the Pre-code group (49%). Fewer garbage codes were used in the Code group with an average of .5 in the Pre-code group and .3 in the Code group. No significant difference was identified in major error occurrences except for in the garbage codes. Minor errors were more common in the Pre-code group than in the Code group.
The overall use of garbage codes on DCs could be reduced by changing the process by which physicians complete DCs, that is, the application of documenting ICD disease codes directly as the COD on DCs.
本研究旨在确定在死亡证明（DC）上直接应用国际疾病分类（ICD）疾病代码作为死因（COD），而不是手写或输入 COD，是否可以减少垃圾代码的使用。
从 2016 年 4 月开始，对文件记录流程进行了更改，废除了在 DC 上手写或输入 COD 的流程，改为直接应用患者治疗过程中登记的 ICD 疾病代码。回顾性分析了在实施直接在 DC 上应用 ICD 疾病代码之前（预代码组）和之后（代码组）一年期间急诊科（ED）签发的 DC。比较了两组之间垃圾代码以及其他主要和次要错误的发生情况。由四位急诊医生对错误进行调查和判断。
代码组（25%）的总体垃圾代码发生率明显低于预代码组（49%）。代码组中使用的垃圾代码较少，预代码组中平均为.5 个，代码组中为.3 个。除了垃圾代码外，主要错误的发生率没有明显差异。次要错误在预代码组中比在代码组中更常见。
通过改变医生填写 DC 的流程，即直接将 ICD 疾病代码作为 COD 记录在 DC 上，可以减少 DC 上垃圾代码的总体使用。
