Do we do what they say we do? Coding errors in urology
Do we do what they say we do? Coding errors in urology
复制标题
DOI：
10.1046/j.1464-410x.2000.00471.x
复制
发表时间：
2000-03-01
影响因子：
4.5
通讯作者：
Emberton, M
中科院分区：
文献类型：
--
作者：
Ballaro, A;Oliver, S;Emberton, M
目的探讨大型多专科泌尿外科常规数据编码的准确性。材料与方法从临床记录中，由2名泌尿外科实习生对106例泌尿外科完成会诊事件（fce）进行诊断和程序编码。将这些代码与初级医务人员填写在审计表上的信息中由专业医院编码人员（受训人员不知情）所归属的代码进行比较。如果编码中存在差异，则记录错误，并确定编码过程中发生错误的阶段。结果106例fce中有38例（36%）出现48个编码错误；34例（71%）是由于编码不准确造成的，14例（29%）是由于审核表格填写不正确造成的。结论作者所在科室生成的临床编码不能准确反映临床实际情况。如果这种程度的编码错误一般是泌尿科单位的典型，那么除非数据记录被赋予更高的优先权，否则医院绩效表（将使用常规临床数据生成）的概念是站不住脚的。
Objective To determine the accuracy of routine data coding in a large multispeciality urological unit.Materials and methods From the clinical records, the diagnosis and procedure codes were ascribed to 106 finished consultant episodes (FCEs) in urology, by two urological trainees. The codes were compared with those ascribed by professional hospital coders land of which the trainees were unaware) from information written on the audit form by junior medical staff. Where there were discrepancies in codes an error was recorded and the stage in the coding process in which it occurred was determined.Results Forty-eight coding errors were found in 38 of the 106 (36%) FCEs; 34 (71%) were caused by inaccurate coding and 14 (29%) were the result of the incorrect completion of audit forms,Conclusion The clinical codes generated from the authors' department do not accurately reflect the clinical practice. If coding errors of this magnitude are typical of urology units in general, the concept of hospital performance tables (which will be generated using routine clinical data) is untenable unless data recording is given higher priority.