Schwartz R J, Nightingale B S, Boisoneau D, Jacobs L M
Department of Emergency Medicine/Trauma, Hartford Hospital, CT, USA.
Acad Emerg Med. 1995 Jul;2(7):615-20. doi: 10.1111/j.1553-2712.1995.tb03599.x.
To determine the accuracy of ICD-9-CM external-cause-of-injury codes (e-codes) assigned to the medical records of injured patients treated in an ED and released.
A comparison was made of routine coding and expert recoding of medical records generated in the ED for a convenience sample of patients treated for injuries within 24 hours of injury occurrence and subsequently released from the ED. The medical record was handwritten and subsequently coded by three medical records coders (MRCs). The e-coded charts were sent to an external medical record consultant (expert), who was blinded to the codes previously assigned. The expert reading was used as the criterion standard. Accuracy was measured using a kappa statistic, and errors were described.
Of 126 available patient charts, 108 (85.7%) were assigned e-codes by MRCs. The expert assigned two codes to (double-coded) 67 patients, while the MRCs double-coded only one patient. The additional code was usually a "place of occurrence code." In 60 cases (55.6%), the expert code exactly matched the MRC code; kappa = 0.462. Of the 48 mismatches (44.4%), 20 (41.7%) were e-coded in the wrong category, 20 (41.7%) were e-coded in the correct category but with incorrect specificity of information, either too specific or not specific enough, and eight (16.6%) had combined coding errors.
The accuracy of e-codes assigned to ED records was moderate in this single institution analysis. Errors were predominantly related to the specificity of the code, but some e-codes were in the wrong category. There are implications for injury surveillance and research. E-code assignment must be standardized and applied uniformly to obtain accurate codes. Automation of e-coding could improve accuracy and consistency of codes. National and international epidemiologic studies of cause of injury among ED patients will be severely hampered until e-code assignment can be better standardized.
确定分配给在急诊科接受治疗并出院的受伤患者病历的国际疾病分类第九版临床修订本（ICD - 9 - CM）外部损伤原因编码（电子编码，e编码）的准确性。
对急诊科生成的病历进行常规编码与专家重新编码的比较，这些病历来自一个便利样本，样本中的患者在受伤后24小时内接受了损伤治疗并随后从急诊科出院。病历为手写，随后由三名病历编码员（MRC）进行编码。已进行电子编码的病历被发送给一名外部病历顾问（专家），该专家对先前分配的编码不知情。专家解读被用作标准参照。使用kappa统计量测量准确性，并描述错误情况。
在126份可用的患者病历中，108份（85.7%）由MRC分配了电子编码。专家为67名患者分配了两个编码（双重编码），而MRC仅对一名患者进行了双重编码。额外的编码通常是“发生地点编码”。在60例（55.6%）中，专家编码与MRC编码完全匹配；kappa = 0.462。在48例不匹配情况（44.4%）中，20例（41.7%）被错误分类进行电子编码，20例（41.7%）被正确分类进行电子编码，但信息特异性错误，要么过于具体要么不够具体，8例（16.6%）存在组合编码错误。
在这个单一机构分析中，分配给急诊科记录的电子编码准确性中等。错误主要与编码的特异性相关，但一些电子编码类别错误。这对损伤监测和研究有影响。电子编码分配必须标准化并统一应用以获得准确编码。电子编码自动化可以提高编码的准确性和一致性。在电子编码分配能够更好地标准化之前，急诊科患者损伤原因的国家和国际流行病学研究将受到严重阻碍。
