Demlo L K, Campbell P M, Brown S S
Med Care. 1978 Dec;16(12):995-1005. doi: 10.1097/00005650-197812000-00003.
Two recent studies by the Institute of Medicine on the reliability of hospital discharge data abstracted from patients' medical records raise serious questions about the adequacy of information on diagnoses and procedures. The findings are particularly timely, since increasingly important decisions about the content of medical care and levels of reimbursement may be based on such information. A series of recommendations are offered to guide the use and improvement of abstracted medical record information.
医学研究所最近进行的两项关于从患者病历中提取的医院出院数据可靠性的研究，对诊断和治疗程序信息的充分性提出了严重质疑。这些研究结果尤为及时，因为关于医疗保健内容和报销水平的决策可能越来越多地基于此类信息。文中提出了一系列建议，以指导提取的病历信息的使用和改进。
