Reliability of information abstracted from patients' medical records.
Two recent studies by the Institute of Medicine on the reliability of hospital discharge data abstracted from patients' medical records raise serious questions about the adequacy of information on diagnoses and procedures. The findings are particularly timely, since increasingly important decisions about the content of medical care and levels of reimbursement may be based on such information. A series of recommendations are offered to guide the use and improvement of abstracted medical record information.
D000043:Abstracting and Indexing; D003933:Diagnosis; D004194:Disease / Q000145:classification; D005069:Evaluation Studies as Topic; D006285:Health Planning; D006769:Hospitals, General / Q000706:statistics & numerical data; D006801:Humans; D007349:Insurance, Health, Reimbursement; D008484:Medicaid; D008499:Medical Records / Q000592:standards*; D006278:Medicare; D010351:Patient Discharge; D011366:Professional Review Organizations; D013223:Statistics as Topic; D014481:United States; D014600:Utilization Review