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住院患者和医疗补助计划参保者中的艾滋病毒感染:病历编码的准确性

HIV infection in hospitalized patients and Medicaid enrollees: the accuracy of medical record coding.

作者信息

Rosenblum L, Buehler J W, Morgan M W, Costa S, Hidalgo J, Holmes R, Lieb L, Shields A, Whyte B

机构信息

Division of HIV/AIDS, National Center for Infectious Diseases, Atlanta, Ga 30333.

出版信息

Am J Public Health. 1993 Oct;83(10):1457-9. doi: 10.2105/ajph.83.10.1457.

Abstract

To evaluate the accuracy of computerized medical-record coding for human immunodeficiency virus (HIV), medical charts were reviewed in six sites. In 7601 hospital and 867 Medicaid records with a listed diagnosis of HIV, the predictive value for HIV was 91% or higher. HIV was identified in 34% of 1155 Medicaid records listing immune disorder or illness in the acquired immunodeficiency syndrome (AIDS) surveillance definition (without an HIV code). In hospital and Medicaid records, AIDS was identified both in records listing AIDS and records listing HIV without AIDS. HIV codes on hospital and Medicaid records were highly predictive for HIV; undercoding of HIV occurred in Medicaid records.

摘要

为评估人类免疫缺陷病毒(HIV)计算机化病历编码的准确性,在六个地点对病历进行了审查。在7601份医院病历和867份列出HIV诊断的医疗补助记录中,HIV的预测值为91%或更高。在1155份列出免疫紊乱或符合获得性免疫缺陷综合征(AIDS)监测定义的疾病(无HIV编码)的医疗补助记录中,34%的记录发现了HIV。在医院和医疗补助记录中,在列出AIDS的记录以及列出HIV但无AIDS的记录中均发现了AIDS。医院和医疗补助记录上的HIV编码对HIV具有高度预测性;医疗补助记录中存在HIV编码不足的情况。

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