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At least 19 recordsLinked to original sources
PubMed1979

Studies on the reliability of vital and health records: I. Comparison of cause of death and hospital record diagnoses.

Based on computer linkage of death records and hospital discharge abstracts, underlying cause of death and discharge diagnoses are compared for 9,724 Vermont resident in-hospital deaths occurring between 1969 and 1975. The agreement between the diagnoses recorded in the two data systems provides a measure of the reproducibility of recording, abstracting, and coding practices. Using the first three digits of the International Classification of Diseases, the agreement between cause and closest medical record diagnosis was 72 per cent. Concordance declined by patient age and length of hospital stay and varied significantly by coded cause of death. A major source of variation was the hospital of death where agreement levels ranged between 45 and 84 per cent. The latter finding is regarded as a potential starting point for targeting investigation of sources of discrepancy and initiating efforts to improve diagnosis recording and coding in the two record systems. The value of both depends on continuing efforts to improve and maintain data quality.

Age Factors↗
PubMed1977

Hospital records of hydatid disease in Victoria for 1970 to 1974.

The records of hydatid disease in 10 Melbourne hospitals and 12 rural hospitals in Victoria from 1970 to 1974 have been studied. In a total of 183 in-patients, the final diagnosis of hydatid disease had been confirmed surgically in 81 first admissions and in 56 readmissions. In 24 cases it was confirmed by necropsy, but in only one of these was hydatid disease believed to have been the cause of death. Figures are given for the age distribution and the organs involved.

Adolescent↗
PubMed1979

Evidential value of the hospital record in clinical decision making.

A simulated retrospective exercise in the diagnosis and management of 53 readmissions to a gastrointestinal unit was undertaken by two consultants. Diagnosis of the illness at readmission was made on evidence sought from a referee, who also supplied, on request, items of relevant evidence from the past medical record. Patient management was agreed from these sources. For each item of evidence the evidential weight, the irrecoverability, and the expected benefit accruing to the patient of its availability was calculated. It was concluded that the evidence worth recording in the event of subsequent hospital admission could be largely specified for each diagnosis and each operation. It would be brief and could be numerically coded.

Decision Making↗
PubMed1978

Shared project studies, revises hospital record retention policies.

Through their shared service organization, six hospitals conducted a study that showed that they had similar practical needs and legal requirements for medical record retention but widely varying retention policies. Written policies that were developed for and jointly adopted by the hospitals have ensured consistent, cost-effective retention practices.

California↗