title: [Reliability of coding of diagnoses recorded in the computerized information system at primary health care centers].
abstract: 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.
authors.affiliation: Consejería de Sanidad y Política Social, Murcia.
authors.forename: E
authors.initials: E
authors.lastname: Fernández Herráez
authors.forename: M L
authors.initials: ML
authors.lastname: Usera Clavero
authors.forename: P
authors.initials: P
authors.lastname: Parra Hidalgo
authors.forename: P J
authors.initials: PJ
authors.lastname: Saturno Hernández
authors.forename: J
authors.initials: J
authors.lastname: Saura Llamas
authors.forename: J J
authors.initials: JJ
authors.lastname: Herranz Valera
mesh_terms: D003151:Community Health Centers; D003933:Diagnosis; D016347:Medical Records Systems, Computerized / Q000592:standards*; D011320:Primary Health Care
vernacular_title: Fiabilidad de la codificación del diagnóstico registrado en las hojas de consulta del sistema de información informatizado de centros de atención primaria (SICAP).