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Titolo:
Coding diagnoses and procedures using a high-quality clinical database instead of a medical record review
Autore:
van Walraven, C; Demers, SV;
Indirizzi:
Ottawa Civic Hosp, Loeb Res Inst, Clin Epidemiol Unit, Ottawa, ON K1Y 4E9,Canada Ottawa Civic Hosp Ottawa ON Canada K1Y 4E9 nit, Ottawa, ON K1Y 4E9,Canada
Titolo Testata:
JOURNAL OF EVALUATION IN CLINICAL PRACTICE
fascicolo: 3, volume: 7, anno: 2001,
pagine: 289 - 297
SICI:
1356-1294(200108)7:3<289:CDAPUA>2.0.ZU;2-F
Fonte:
ISI
Lingua:
ENG
Soggetto:
ACUTE MYOCARDIAL-INFARCTION; DISCHARGE SUMMARIES; CLAIMS;
Keywords:
administrative databases; coding; discharge abstract; discharge summary;
Tipo documento:
Article
Natura:
Periodico
Settore Disciplinare:
Clinical Medicine
Citazioni:
33
Recensione:
Indirizzi per estratti:
Indirizzo: van Walraven, C Ottawa Civic Hosp, Loeb Res Inst, Clin Epidemiol Unit, F-6,Civ Campus,1053Carling Ave, Ottawa, ON K1Y 4E9, Canada Ottawa Civic Hosp F-6,Civ Campus,1053 Carling Ave Ottawa ON Canada K1Y 4E9
Citazione:
C. van Walraven e S.V. Demers, "Coding diagnoses and procedures using a high-quality clinical database instead of a medical record review", J EVAL CL P, 7(3), 2001, pp. 289-297

Abstract

A discharge abstract must be completed for each hospitalization. The most time-consuming component of this task is a complete review of the doctors' progress notes to identify and code all diagnoses and procedures. We have developed a clinical database that creates hospital discharge summaries. To compare diagnostic and procedural coding from a clinical database vs. the standard chart review by health records analysts (HRA). All patients admitted and discharged from general medical and surgical services at a teaching hospital in Ontario, Canada. Diagnostic and procedural codes were identifiedby reviewing discharge summaries generated from a clinical database. Independently, codes were identified by hospital health records analysts using chart review alone. Codes were compared with a gold standard case review conducted by a health records analyst and a doctor. Coding accuracy (percentage of codes in gold standard review) and completeness (percentage of gold standard codes identified). The study included 124 patients (mean length of stay 5.5 days; 66.4% medical patients). The accuracy of the most responsiblediagnosis was 68.5% and 62.9% for the database (D) and chart review (C), respectively (P=0.18). Overall, the database significantly improved the accuracy (D= 8.9% vs. C=74.5%; P=0.02) and completeness (D=63.9% vs. C=36.7%; P<0.0001) of diagnostic coding. Although completeness of procedural coding was similar (D=5.4% vs. C=64.2%; P=NS), accuracy decreased with the database(D=70.3% vs. C=92.2%; P < 0.0001). Mean resource intensity weightings calculated from the codes (D=1.3 vs. C=1.4; P=NS) were similar. Coding from a clinical database may circumvent the need for HRAs to review doctors' progress notes, while maintaining the quality of coding in the discharge abstract.

ASDD Area Sistemi Dipartimentali e Documentali, Università di Bologna, Catalogo delle riviste ed altri periodici
Documento generato il 27/01/20 alle ore 07:26:54