Fox K M, Reuland M, Hawkes W G, Hebel J R, Hudson J, Zimmerman S I, Kenzora J, Magaziner J
University of Maryland at Baltimore, Department of Epidemiology and Preventive Medicine, USA.
J Am Geriatr Soc. 1998 Jun;46(6):745-50. doi: 10.1111/j.1532-5415.1998.tb03810.x.
To determine the accuracy of diagnoses and procedure codes in medical records for hip fracture patients.
A validation sample of hip fracture medical records was used to compare the facesheet data with progress notes, operative reports, and discharge summaries for patients in a prospective study of functional recovery.
Eight Baltimore hospitals with the highest volume of older hip fracture patients.
Study subjects were 343 community-dwelling patients, 65 years of age and older, admitted to one of eight Baltimore hospitals between January 1990 and June 1991 with a diagnosis of hip fracture.
Facesheet diagnosis codes were compared with admitting notes, discharge summary, and/or progress notes. The abstracted surgical procedure was compared with postoperative radiographs.
Excess coding of diagnoses on the hospital facesheet was evident in 12% of charts. In 17% of charts, a complication identified in the chart was not coded on the facesheet. More complications with low severity were omitted. Agreement between the abstractor's procedure review and radiograph readings for arthroplasty was 84%. In 15% of patients, the abstractor coded total arthroplasty when hemiarthroplasty was done.
Discrepancy between the hospital facesheet and the medical record and between the abstracted surgical procedure and radiographs was found for hip fracture patients. This may make findings from health outcomes research relying on administrative databases uncertain and reimbursement inaccurate.
确定髋部骨折患者病历中诊断和手术编码的准确性。
在一项关于功能恢复的前瞻性研究中，使用髋部骨折病历的验证样本，将病历首页数据与患者的病程记录、手术报告和出院小结进行比较。
巴尔的摩八家收治老年髋部骨折患者数量最多的医院。
研究对象为343名65岁及以上的社区居住患者，于1990年1月至1991年6月间入住巴尔的摩八家医院之一，诊断为髋部骨折。
将病历首页诊断编码与入院记录、出院小结和/或病程记录进行比较。将提取的外科手术与术后X光片进行比较。
12%的病历中存在医院病历首页诊断编码过多的情况。17%的病历中，病历中确定的并发症未在病历首页编码。更多低严重程度的并发症被遗漏。关节置换术的提取手术评估与X光片读数之间的一致性为84%。15%的患者在进行半关节置换术时，提取人员编码为全关节置换术。
发现髋部骨折患者的医院病历首页与病历之间以及提取的外科手术与X光片之间存在差异。这可能使依赖行政数据库的健康结局研究结果不确定，报销不准确。
