Survey on Discordance Rate between Final Principal Diagnosis and Principal Diagnosis at Emergency Room

Kim, Kwang Hwan; Seo, Sun Won; Won, Si Yeon; Park, Seok Gun; Kim, Seung Yul; Song, Hwa Sik; Kim, Kab Taug; Jo, Hey Kyung; Bu, You Kung; Lee, Hyun Kyung

Journal of Korean Society Quality Assurance Health Care 1998;5(2): 216.
Published online December 30, 1998.

응급실 주진단명과 퇴원시 주진단명의 불일치도 조사

김광환¹, 서순원¹, 원시연¹, 박석건², 김승렬³, 송화식³, 김갑득³, 조혜경⁴, 부유경⁵, 이현경⁶

¹단국대학교병원 의무기록과
²단국대학교병원 핵의학과
³단국대학교병원 응급의학과
⁴을지대학병원 의무기록실
⁵인하대학교병원 의무기록과
⁶대전보건대학 의무행정과

Survey on Discordance Rate between Final Principal Diagnosis and Principal Diagnosis at Emergency Room

Kwang Hwan Kim¹, Sun Won Seo¹, Si Yeon Won¹, Seok Gun Park², Seung Yul Kim³, Hwa Sik Song³, Kab Taug Kim³, Hey Kyung Jo⁴, You Kung Bu⁵, Hyun Kyung Lee⁶

¹Department of Medical Record, Dankook University Hospital
²Department of Nuclear Medicine, Dankook University Hospital
³Department of Emergency Medicine, Dankook University Hospital
⁴Department of Medical Record, Ulgi University Hospital
⁵Department of Medical Record, Inha University Hospital
⁶Taejon Health Sciences College Medical Administration

Abstract

We surveyed the discordance rate of principal diagnosis made at emergency room(ER) & made at ward on discharge of the patients. Subjects were four hundred eighty cases who came to the ER of one third-line hospital from January 1, 1998 to January 31, 1998. The discordance rate was higher in patients admitted to medical department(8.2%) than surgical department(1.5%). If the patients were transferred to other department during hospital stay, discordance rate increased from 3.3% to 6.3%. In conclusion, discordance rate of principal diagnosis made at ER and made at ward was higher in patients with complicated problems. Medical record department should keep these findings in mind if it has a plan to support the management of ER record.

Key words emergency room diagnosis;medical records;