Methods Inf Med - Long-term impact of physician encoding on detail and number of recorded diagnoses. Support by a speciality specific list of diseases.

Tópicos

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{ high(1669) rate(1365) level(1280) }
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{ detect(2391) sensit(1101) algorithm(908) }

Resumo

JECTIVES: To improve the recording of diagnostic discharge data, pediatricians encoded diagnostic information as part of discharge letter writing supported by a pediatric list of ICD-9-CM-based codes. We evaluated the effect of this new policy on level of detail and number of recorded diagnoses.METHODS: We compared proportions of specific principal diagnoses and numbers of secondary diagnoses of the four years before with the eight years after introduction.RESULTS: Immediately after introduction, half of the diagnoses for which both generic and specific codes existed was coded specific. In later years this proportion remained stable at 0.35 (p <0.05). Diagnoses that fall under the pediatrician's own subspecialty had more often a specific code than diagnoses that do not. The mean number of secondary diagnoses per admission increased from 0.7 before introduction to 1.4 in the third year after introduction (p <0.05) but gradually fell back to 0.7. This increase and decrease was mainly due to diagnoses that did not fall under the pediatrician's own subspecialty. The extra codes in individual discharge summaries had added informational value.CONCLUSIONS: Discharge letter-linked encoding by pediatricians supported by a pediatric list of diseases leads initially to increased detail and number of diagnoses with added informational value. When attention diminishes, especially the level of detail and number of secondary diagnoses that do not fall under one's own subspecialty decrease. The level of detail of principal diagnoses remains stable because of the advantage for pediatricians of having specific diagnostic codes falling under their own subspecialty.

Resumo Limpo

jectiv improv record diagnost discharg data pediatrician encod diagnost inform part discharg letter write support pediatr list icdcmbas code evalu effect new polici level detail number record diagnosesmethod compar proport specif princip diagnos number secondari diagnos four year eight year introductionresult immedi introduct half diagnos generic specif code exist code specif later year proport remain stabl p diagnos fall pediatrician subspecialti often specif code diagnos mean number secondari diagnos per admiss increas introduct third year introduct p gradual fell back increas decreas main due diagnos fall pediatrician subspecialti extra code individu discharg summari ad inform valueconclus discharg letterlink encod pediatrician support pediatr list diseas lead initi increas detail number diagnos ad inform valu attent diminish especi level detail number secondari diagnos fall one subspecialti decreas level detail princip diagnos remain stabl advantag pediatrician specif diagnost code fall subspecialti

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