Quality of morbidity coding in general practice computerized medical records: a systematic review
Quality of morbidity coding in general practice computerized medical records: a systematic review
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DOI：
10.1093/fampra/cmh409
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发表时间：
2004-08-01
期刊：
影响因子：
2.2
通讯作者：
Croft, P
中科院分区：
文献类型：
--
作者：
Jordan, K;Porcheret, M;Croft, P
背景在初级保健服务和研究中越来越多地使用计算机和发病率编码，这就需要证明全科医疗记录的质量。我们的目的是评估质量，在完整性和正确性方面，通过系统的审查，在计算机化的全科医疗记录的发病率编码。通过检索电子数据库和引用收集的论文来识别已发表的研究。由两名独立观察员对每一条款进行评估，并以协商一致方式解决差异。由于研究的异质性，我们对其进行了定性的综述。24项研究符合审查的纳入标准。研究的方法和质量各不相同，而且在概括性方面存在问题。研究试图通过参考纸质记录、处方信息或诊断测试和程序等黄金标准来评估发病率登记的完整性和正确性，但每一种标准都存在问题。一个一致的发现是，记录的质量不同的发病率。其中一个原因可能是诊断的独特性（例如，糖尿病编码的质量往往高于哮喘编码）。这篇综述强调了在评估计算机化全科医疗记录的完整性和正确性时所面临的问题。然而，它也表明可以实现高质量的编码。现在的重点应该放在鼓励和帮助实践提高编码质量的方法上。
Background. Increased use of computers and morbidity coding in primary care delivery and research brings a need for evidence of the quality of general practice medical records.Objective. Our aim was to assess the quality, in terms of completeness and correctness, of morbidity coding in computerized general practice records through a systematic review.Methods. Published studies were identified by searches of electronic databases and citations of collected papers. Assessment of each article was made by two independent observers and discrepancies resolved by consensus. Studies were reviewed qualitatively due to their heterogeneity.Results. Twenty-four studies met the inclusion criteria for the review. There was variation in the methodology and quality of studies, and problems in generalizability. Studies have attempted to assess the completeness and correctness of morbidity registers by reference to a gold standard such as paper notes, prescribing information or diagnostic tests and procedures, each of which has problems. A consistent finding was that quality of recording varied between morbidities. One reason for this may be in distinctiveness of diagnosis (e.g. coding of diabetes tended to be of higher quality than coding of asthma).Conclusions. This review highlights the problems faced in assessing the completeness and correctness of computerized general practice medical records. However, it also suggests that a high quality of coding can be achieved. The focus should now be on methods to encourage and help practices improve the quality of their coding.