[Reliability of coding of diagnoses recorded in the computerized information system at primary health care centers].
OBJECTIVE
To find the reliability of the coding of diagnoses in the doctor's note in this computer system and to analyse where there are most discrepancies.


METHODS
An observational study. The concordance between the reason for consultation, codified by an external assessor, and the coding of the main diagnosis.


METHODS
Health Districts 17 (Murcia/Barrio del Carmen) and 66 (Molina de Segura/La Ribera) in the Autonomous Community of Murcia.


METHODS
A sub-sample of 228 consultations, belonging to a larger study of 1,904 general medical consultations (total: 98,768 consultations).


RESULTS
There were discrepancies between the coding of the reason for consultation and the diagnosis in 23% of the consultations recorded. The reason for consultation was not correctly recorded in 12.3%. The diagnostic group or section with the highest level of agreement was number XVIII or the supplementary section; and with the least agreement in XVII (injuries and adverse side-effects) and Number V covering mental disorders.


CONCLUSIONS
Quality control of information and its validation enables errors and problems in the systems to be identified and corrected. This study points to the need to improve the filling-out of the reason for consultation and activity carried out, in order to obtain afterwards a more reliable coding of the diagnosis.
Fernández Herráez
E
E
Consejería de Sanidad y Política Social, Murcia.
Usera Clavero
M L
ML
Parra Hidalgo
P
P
Saturno Hernández
P J
PJ
Saura Llamas
J
J
Herranz Valera
J J
JJ
D003151:Community Health Centers; D003933:Diagnosis; D016347:Medical Records Systems, Computerized / Q000592:standards*; D011320:Primary Health Care
Fiabilidad de la codificación del diagnóstico registrado en las hojas de consulta del sistema de información informatizado de centros de atención primaria (SICAP).