Demlo L K, Campbell P M
Med Care. 1981 Oct;19(10):1030-40. doi: 10.1097/00005650-198110000-00005.
The most recent study by the Institute of Medicine of the reliability of hospital discharge data abstracted from patients' medical records documents the continuing presence of a substantial level of imprecision and error, affirming the findings of earlier studies. The most obvious factors leading to unreliability stem from inadequacies in the face sheets of medical records. Significant improvements could be attained if the discharge summary were routinely used to abstract information on patient disposition and principal diagnosis and if the operative report were routinely used to abstract information on principal procedure. Additional recommendations are offered for developmental activities intended to improve the designation of diagnosis, diagnostic classification schemes and hospital medical records systems.
医学研究所关于从患者病历中提取的医院出院数据可靠性的最新研究记录了持续存在的大量不精确性和错误，证实了早期研究的结果。导致不可靠性的最明显因素源于病历首页的不足。如果出院小结被常规用于提取患者处置和主要诊断信息，并且手术报告被常规用于提取主要手术信息，就可以取得显著改进。还针对旨在改进诊断指定、诊断分类方案和医院病历系统的发展活动提出了其他建议。
