[Error ratio in International Classification of Diseases coding and implementation of the nursing personnel regulation of the Health Organization Law].
Since 1 January, 1993, it has been a legal requirement to enter, for identification of the main diagnosis, the appropriate code from the International Classification of Diseases (ICD) on the documentation forms of the Nursing Personnel Regulation as prescribed under the (German Federal Government's) Health Organization Law. This study was undertaken to analyse the frequency of errors in this coding and the reasons for it. The data of the Nursing Personnel Regulations during the first 6 months of 1993 were compared with the corresponding entries in the diagnostic archives. In 671 of 2308 analysed forms (29%) coding errors were discovered. The rate of errors was especially high in the areas of cardiology (39%), angiology (37%), nephrology (36%) and neurology (35%). However, a high percentage of the wrong codings for cardiological and nephrological diseases were still within the same diagnostic field.--These findings indicate that, to ensure quality, those doctors who do the coding should be fully informed about the potential consequences regarding staffing of such errors. All coding must be done by experienced doctors, be locally checked and, if technically possible, compared with the diagnostic archive entries. Also, the registration of only one main diagnosis is not sensible in the case of patients with multi-organ disease.
König
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Medizinische Klinik, Klinikum Innenstadt, Universität München.
Rau
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R
Scriba
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PC
D004194:Disease / Q000145:classification*; D005568:Forms and Records Control / Q000331:legislation & jurisprudence; D005858:Germany; D006801:Humans; D007884:Legislation, Nursing; D009737:Nursing Records / Q000331:legislation & jurisprudence / Q000592:standards*; D012984:Software
Fehlerquote bei der ICD-Verschlüsselung und Realisierbarkeit der Pflege-Personalregelung des Gesundheitsstrukturgesetzes.