Abstract
Effective planning and evaluation of medical services is only possible if appropriate and reliable information is available. Diagnoses of patients seen are essential data. The epidemiological value of standard, reliable diagnostic data could also be considerable. The International Classification of Diseases (ICD) is the only system currently available which provides a common basis of classification for general statistical use. A booklet, using ICD codes, for classifying in-patients and out-patients seen by neurologists has been developed. It is simple and easy to use, affords the necessary economy of time, and should result in uniformity of coding. Reliability studies confirm that inaccuracies occur when patients' diagnoses are coded retrospectively from their medical files, even when observers are medically trained. It is recommended that doctors should accept personal responsibility for coding patients' diagnoses at the time of consultation or discharge from hospital.
Full text
PDF
Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Black D. Data for management: the Körner Report. Br Med J (Clin Res Ed) 1982 Oct 30;285(6350):1227–1228. doi: 10.1136/bmj.285.6350.1227. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Connell F. A., Blide L. A., Hanken M. A. Ambiguities in the selection of the principal diagnosis: impact on data quality, hospital statistics and DRGs. J Am Med Rec Assoc. 1984 Feb;55(2):18–23. [PubMed] [Google Scholar]
- Kennedy G. T., Stern M. P., Crawford M. H. Miscoding of hospital discharges as acute myocardial infarction: implications for surveillance programs aimed at elucidating trends in coronary artery disease. Am J Cardiol. 1984 Apr 1;53(8):1000–1002. doi: 10.1016/0002-9149(84)90625-8. [DOI] [PubMed] [Google Scholar]
- Lloyd S. S., Rissing J. P. Physician and coding errors in patient records. JAMA. 1985 Sep 13;254(10):1330–1336. [PubMed] [Google Scholar]
- Martini C. J., Hughes A. O., Patton V. A. A study of the validity of the Hospital Activity Analysis information. Br J Prev Soc Med. 1976 Sep;30(3):180–186. doi: 10.1136/jech.30.3.180. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Whates P. D., Birzgalis A. R., Irving M. Accuracy of hospital activity analysis operation codes. Br Med J (Clin Res Ed) 1982 Jun 19;284(6332):1857–1858. doi: 10.1136/bmj.284.6332.1857. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Williams B. The use and misuse of bed-occupancy and waiting-list figures. Lancet. 1968 May 11;1(7550):1029–1030. doi: 10.1016/s0140-6736(68)91128-8. [DOI] [PubMed] [Google Scholar]