[标准化出院小结中医疗信息的质量评估]
[Quality assessment of the medical information on the standardized discharge summary].
作者信息
Vergnon P, Morgon E, Dargent S, Benyamine D, Favre M, Perrot L, Pradat E, Colin C
机构信息
Département d'Information Médicale des Hospices Civils de Lyon.
出版信息
Rev Epidemiol Sante Publique. 1998 Feb;46(1):24-33.
BACKGROUND
DRG-based management of public hospitals in France involves the use of standardised discharge abstracts for the "Medicalisation of Information Systems Program".
METHODS
To assess the quality of the medical information in these abstracts, a sample of 649 abstracts for 1994 was collected from the Hospices Civils de Lyon's data base. To validate the information in these abstracts, we reviewed the medical records of each patient.
RESULTS
The results showed an error rate of 32% (CI: 28-36) for the diagnosis-related group and an error rate of 40% (CI: 36-44) for the principal diagnosis. There was no significant difference between these error rates and the calculation of "Indices Synthétiques d'Activité" (French system for attributing points to hospital stays according to DRGs categories).
CONCLUSIONS
The quality of the medical information for the "Medicalisation of Information Systems Program" remains a major challenge not only for budget allocation, but also for the study of the case-mix in hospitals.
背景
法国公立医院基于疾病诊断相关分组（DRG）的管理涉及为“信息系统医疗化项目”使用标准化出院摘要。
方法
为评估这些摘要中医疗信息的质量，从里昂市立医院数据库收集了1994年的649份摘要样本。为验证这些摘要中的信息，我们查阅了每位患者的病历。
结果
结果显示，诊断相关分组的错误率为32%（置信区间：28 - 36），主要诊断的错误率为40%（置信区间：36 - 44）。这些错误率与“综合活动指数”（法国根据DRG类别为住院病例分配分数的系统）的计算之间没有显著差异。
结论
“信息系统医疗化项目”的医疗信息质量仍然是一个重大挑战，不仅对于预算分配，而且对于医院病例组合的研究而言。
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