IMPROVING HOSPITAL DISCHARGE DATA - LESSONS FROM THE NATIONAL HOSPITAL DISCHARGE SURVEY
IMPROVING HOSPITAL DISCHARGE DATA - LESSONS FROM THE NATIONAL HOSPITAL DISCHARGE SURVEY
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DOI：
10.1097/00005650-198110000-00005
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发表时间：
1981-01-01
期刊：
影响因子：
3
通讯作者：
CAMPBELL, PM
中科院分区：
文献类型：
--
作者：
DEMLO, LK;CAMPBELL, PM
医学研究所对从病人病历中提取的出院数据的可靠性进行的最新研究证明，仍然存在相当大程度的不准确和错误，这肯定了先前研究的结果。导致不可靠的最明显因素来自于医疗记录正面页的不足。如果常规使用出院摘要来提取关于患者处置和主要诊断的信息，如果常规使用手术报告来提取关于主要程序的信息，则可以获得显著的改善。对旨在改进诊断、诊断分类方案和医院病历系统设计的发展活动提出了其他建议。
The most recent study by the Institute of Medicine of the reliability of hospital discharge data abstracted from patients' medical records documents the continuing presence of a substantial level of imprecision and error, affirming the findings of earlier studies. The most obvious factors leading to unreliability stem from inadequacies in the face sheets of medical records. Significant improvements could be attained if the discharge summary were routinely used to abstract information on patient disposition and principal diagnosis and if the operative report were routinely used to abstract information on principal procedure. Additional recommendations are offered for developmental activities intended to improve the designation of diagnosis, diagnostic classification schemes and hospital medical records systems.