PHYSICIAN AND CODING ERRORS IN PATIENT RECORDS
PHYSICIAN AND CODING ERRORS IN PATIENT RECORDS
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DOI：
10.1001/jama.254.10.1330
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发表时间：
1985-01-01
影响因子：
120.7
通讯作者：
RISSING, JP
中科院分区：
文献类型：
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作者：
LLOYD, SS;RISSING, JP
对退伍军人管理局的[美国]出院摘要系统进行了研究，以确定退伍军人管理局五家医院的错误频率、来源和影响。我们审查了来自 21 个服务机构的 1829 份医疗记录，以确保其与摘要一致；抽样为每项服务提供了 95% 的置信度。在这些记录中，1499 条 (82%) 至少有一项与摘要不同。在 20,260 项中，有 4360 项 (22%) 不正确，错误来源有三个：医生 (62%)、编码 (35%) 和按键 (3%)。我们预计摘要中平均有 2.14 个医生错误和 0.81 个编码错误。百分之八十九的预计医生错误是未能报告手术或诊断。编码是主观的，错误与医生错误是协同的。我们预计，错误更正将更改 19% 的用于诊断相关组目的的记录，并大幅增加未来的资源分配。这种效果因服务的不同而有很大差异。
The Veterans Administration''s [USA] discharge abstract system was studied to identify error frequency, source, and effect in five Veterans Administration hospitals. We reviewed 1829 medical records from 21 services for concordance with the abstract; sampling provided 95% confidence for each service. Of these records, 1499 (82%) differed from the abstract in at least one item. Of 20,260 items, 4360 (22%) were incorrect, with three error sources: physician (62%), coding (35%), and keypunch (3%). We projected 2.14 physician and 0.81 coding errors in the average abstract. Eighty-nine percent of projected physician errors were failures to report a procedure or diagnosis. Coding was subjective and errors were synergistic with physician errors. We projected that correction of errors would change 19% of the records for diagnosis-related group purposes and substantially increase future resource allocation. This effect varied considerably by service.