Gibson N, Bridgman S A
School of Postgraduate Medicine, University of Keele.
Ann R Coll Surg Engl. 1998 Jul;80(4):293-6.
The aim of this study was to describe the accuracy of diagnostic coding in general surgery in a district general hospital, the North Staffordshire Hospital NHS Trust (NSHT), Stoke-on-Trent. An assessment was carried out by comparison between codes ascribed by hospital coders and expert external coders. Patients who had a finished consultant episode (FCE) in the specialty of general surgery at NSHT were included in the study. The sampling frame was general surgery FCEs at NSHT purchased by North Staffordshire Health Authority (NSHA) with an episode end date between 1 May 1995 and 31 December 1995. Every 15th record was sampled. Of 455 records sampled, 157 (35%) were in active use and were excluded but not replaced; therefore, 298 (65%) records were studied in detail. Outcome was measured by the accuracy of primary diagnostic codes ranked 1, 2, 3, 4, from highest to lowest levels of inaccuracy; a description of where errors occurred in the data cycle was recorded. Errors were found in 87/298 (29%) records; 25/298 (8%) records had an error at the highest level (i.e. wrong ICD-10 chapter), and 44/298 (15%) at the third level. Of the errors, 68/87 (78%) occurred between the medical record and the admission form. A substantial percentage (29%) of records had inaccurate diagnostic codes. It is concluded that coding should be carried out from the medical record rather than from the admission form (KMR1). The proportion of records with errors suggests that a routine data coding audit would be useful to improve the accuracy of routine diagnostic codes.
本研究旨在描述北斯塔福德郡医院国民保健服务信托基金（NSHT），即特伦特河畔斯托克的一家地区综合医院普通外科诊断编码的准确性。通过比较医院编码员和外部专家编码员赋予的编码进行评估。纳入研究的患者为在NSHT普通外科专科完成了顾问诊疗过程（FCE）的患者。抽样框架是北斯塔福德郡卫生局（NSHA）购买的NSHT普通外科FCE，诊疗过程结束日期在1995年5月1日至1995年12月31日之间。每15条记录抽取一条样本。在抽取的455条记录中，157条（35%）正在使用，被排除且未被替换；因此详细研究了298条（65%）记录。结果通过从最高到最低不准确程度排列的1、2、3、4级主要诊断编码的准确性来衡量；记录了数据循环中错误发生的位置。在298条记录中的87条（29%）发现了错误；298条记录中的25条（8%）在最高级别（即错误的ICD - 10章节）有错误，298条记录中的44条（15%）在第三级别有错误。在这些错误中，68/87（78%）发生在病历和入院表格之间。相当比例（29%）的记录诊断编码不准确。得出结论：编码应从病历而非入院表格进行（KMR1）。有错误记录的比例表明，常规数据编码审核对于提高常规诊断编码的准确性将是有用的。
