Trauma patients without a trauma diagnosis: the data gap at a level one trauma center.
Trauma patients without a trauma diagnosis: the data gap at a level one trauma center.
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没有创伤诊断的创伤患者：一级创伤中心的数据差距。
DOI：
10.1097/ta.0b013e31818c1583
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发表时间：
2009
期刊：
影响因子：
--
通讯作者：
vonRecklinghausen,FriedrichM
中科院分区：
文献类型：
--
作者：
Whedon,JamesM;Fulton,Gwen;Herr,CharlesH;vonRecklinghausen,FriedrichM
背景：创伤注册表可能包含没有可编码创伤诊断的记录，造成“数据缺口”，使无效注册表数据字段的数量成倍增加。我们设计了一项调查，旨在确定登记记录中不可编码创伤诊断的发生率，描述这些记录的特征，并确定诊断数据不足的原因。方法：采用回顾性队列设计。对创伤登记记录进行了5年的查询，得到129条没有损伤严重程度评分的记录。每个病人的医疗记录被审查，诊断信息的来源被记录，诊断被分类。结果：在57%的病例中，我们发现患者有受伤的记录，但在出院总结中没有充分记录损伤。在19%的病例中，虽然登记记录是有效的，但诊断不能被编码为创伤。在17%的病例中，临床文件是充分的，但在创伤登记处的诊断记录不充分。在13%的病例中，尽管登记记录是有效的，但没有创伤性损伤。在2%的病例中，创伤登记记录本身是无效的。在1%的情况下，发生了编码错误。在出院文件不充分的记录中，特别突出的是没有放射学证据的头部和脊柱损伤病例。结论：通过改进医生记录、修订创伤登记纳入标准、增加创伤登记员对主要文件来源的关注以及必要时与主治医生直接沟通，可以最好地减少诊断不编码的记录发生率。
Background:Trauma registries may contain records without a codable trauma diagnosis, creating a “data gap” that multiplies the number of invalid registry data fields. We designed an investigation intended to determine the incidence of registry records with noncodable trauma diagnoses, characterize those records, and determine the reasons for inadequate diagnosis data.Methods:We used a retrospective cohort design. A query of trauma registry records spanning a 5-year period yielded 129 records with no injury severity score. Each patient's medical record was reviewed, sources of diagnostic information were noted, and diagnoses were categorized.Results:In 57% of cases, we found documentation that the patient had sustained an injury, but the injury was inadequately documented in the discharge summary. In 19% of cases, although the registry record was valid, the diagnosis was not codable as trauma. In 17% of cases, clinical documentation was adequate, but the diagnosis was inadequately recorded in the trauma registry. In 13% of cases, no traumatic injury was sustained, although the registry record was valid. In 2% of cases, the trauma registry record itself was invalid. In 1% of cases, a coding error occurred. Particularly prominent among records with inadequate discharge documentation were cases of head and spine injury for which there was no radiographic evidence.Conclusions:The incidence of records with noncodable diagnoses might best be reduced through improved physician documentation, revision of trauma registry inclusion criteria, increased attention by trauma registrars to key sources of documentation, and direct communication with the attending physician when necessary.
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调节盘基网柄菌发育事件时间的基因的遗传分析。
DOI：
10.1099/00221287-129-6-1623
发表时间：
1983
期刊：
Journal of general microbiology
影响因子：
--
作者：
K. Abe;Y. Okada;M. Wada;K. Yanagisawa
通讯作者：
K. Yanagisawa
影响因子：
2.7
作者：
D. Waddell;D. Soll
通讯作者：
D. Soll
粘菌盘基网柄菌的形态发生。
影响因子：
2.7
作者：
D. Soll;D. Waddell
通讯作者：
D. Waddell
影响因子：
56.9
作者：
AMBROS, V;HORVITZ, HR
通讯作者：
HORVITZ, HR
盘基网柄菌聚集开始计时器的复杂性和可逆性
影响因子：
2.9
作者：
J. Mercer;D. Soll
通讯作者：
D. Soll