title: Effect of discharge letter-linked diagnosis registration on data quality.
abstract: OBJECTIVE
  Diagnostic data are essential for the assessment of medical practice: they are needed for retrieval of clinical cases and describing co-morbidity and complications. In most Western countries, diagnosis registration in hospital information systems is based mainly on completing forms after patient discharge. As this registration plays no role in patient care, data quality is usually unsatisfactory. To improve data quality, we redesigned the process of diagnosis registration at a paediatric department, and now paediatricians provide diagnoses with codes in a separate registration heading of the discharge letter. We compared the quality of this discharge letter-linked diagnosis registration with the quality of the previous form based registration.
  
  
  METHODS
  Retrospective study with blinded before and after measurement. Re-abstracted diagnosis descriptions of the text of discharge letters were taken as gold standard.
  
  
  METHODS
  A paediatric department in an academic medical centre.
  
  
  METHODS
  From each registration period, 60 admissions were selected randomly. Mean age of the patients was 4.5 (SD +/- 5.5) and 5.2 (SD +/- 5.2) years for the old and new situation respectively. Mean length of stay was 8.8 (SD +/- 11.0) and 7.2 (SD +/- 12.4) days.
  
  
  METHODS
  Discharge letter-linked diagnosis registration.
  
  
  METHODS
  Completeness and accuracy, both at three-digit level of ICD-9-CM.
  
  
  RESULTS
  Completeness of form-based diagnosis registration was 51% (95% CI, 44-58%) and of discharge letter-linked diagnosis registration 54% (95% CI, 47-60%). Accuracy was 65% (95% CI, 58-72%) and 67% (95% CI, 60-74%) respectively.
  
  
  CONCLUSIONS
  The discharge letter-linked diagnosis registration does not provide a better basis for assessment of medical practice than the form based diagnosis registration.
authors.affiliation: Department of Chemical Informatics, Academic Medical Center, Amsterdam, The Netherlands. h.prins@amc.uva.nl
authors.forename: H
authors.initials: H
authors.lastname: Prins
authors.forename: H A
authors.initials: HA
authors.lastname: Büller
authors.forename: J H
authors.initials: JH
authors.lastname: Zwetsloot-Schonk
mesh_terms: D000043:Abstracting and Indexing / Q000592:standards*; D000046:Academic Medical Centers; D002675:Child, Preschool; D004194:Disease / Q000145:classification*; D006801:Humans; D007902:Length of Stay; D008499:Medical Records / Q000592:standards*; D010351:Patient Discharge; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies