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KMID : 0608220090150010123
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Journal of Korean Society of Quality Assurance in Health Care
2009 Volume.15 No. 1 p.123 ~ p.133
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A Study on the agreement of Principal Diagnosis
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Seo Young-Suk
Kim Yoo-Mi
Nam Mun-Hee
Kang Sung-Hong
Lim Ji-Hye
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Abstract
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Background : The principal diagnosis has been used in many different fields such as hospital statistics, medical research, insurance claim, national health statistics and so on. Some principal diagnoses have a relatively low level of reliability in the medium-sized hospitals. The purpose of this study is to identify the reliability level of principal diagnoses and to suggest ways to improve reliability of the principal diagnosis.
Method : Data were collected from a medium-sized hospital located in Pusan. The discharge summaries on 323 patients who were discharged in January, 2008 and the outpatient summaries on 251 patients who visited the hospital on March 28, 2008 were collected, and descriptive analysis was performed using SPSS version 12.0K.
Result : The findings are the followings: (1) the diagnostic consistency rate between medical records and doctors’ was 92.0%; (2) the diagnostic consistency rate between medical records and insurance claims was 86.1%; (3) the diagnostic consistency rate between doctors’ diagnoses and insurance claims was 80.2%. The evidence seems to indicate that some principal diagnoses have reliability problems in the medium-sized hospitals.
Conclusion : The results of this study suggest the followings: (1) employees should be trained and supervision
of hospital activities are needed; (2) network systems should be constructed for each department; (3) professions need to be fostered (4) doctors’ awareness of medical records should be changed.
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KEYWORD
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Principal diagnosis, medical record, coding
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