Langlois J A, Buechner J S, O'Connor E A, Nacar E Q, Smith G S
Office of Health Statistics, Rhode Island Department of Health, Providence, USA.
Am J Public Health. 1995 Sep;85(9):1261-5. doi: 10.2105/ajph.85.9.1261.
Incomplete external cause of injury (E) coding limits the usefulness of hospital discharge data sets for injury surveillance and research. Hospital medical records were examined to determine whether they contained adequate cause of injury documentation to allow for more complete E coding of injury discharges.
Medical records for a sample of discharges involving a principal diagnosis of injury from the Uniform Hospital Discharge Data Set for Rhode Island were selected. We assigned E codes to these discharges and compared our E codes with those of the discharge data set.
Documentation of cause of injury in the medical records was sufficient to allow assignment of a specific E code to 70% of the injuries for which no E codes or vague E codes were submitted on the Uniform Hospital Discharge Data Set. It was estimated that specific cause of injury documentation is available in the medical records of 80% of all injury discharges in Rhode Island; for approximately 90%, an E code describing at least the broad cause of injury could be assigned.
Rates of E coding can be substantially increased by making better use of existing documentation in medical records.
损伤外部原因（E）编码不完整限制了医院出院数据集在损伤监测和研究中的作用。对医院病历进行检查，以确定其中是否包含足够的损伤原因记录，以便对损伤出院进行更完整的E编码。
从罗德岛统一医院出院数据集选取涉及损伤主要诊断的出院样本病历。我们为这些出院病例分配E编码，并将我们分配的E编码与出院数据集的编码进行比较。
病历中的损伤原因记录足以让我们为统一医院出院数据集中70%未提交E编码或提交模糊E编码的损伤病例分配特定的E编码。据估计，罗德岛80%的损伤出院病历中都有具体的损伤原因记录；大约90%的病例可以分配一个至少描述损伤大致原因的E编码。
通过更好地利用病历中的现有记录，可以大幅提高E编码率。
