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Journal of Korean Society Quality Assurance Health Care 2009;15(1): 123.
Published online June 30, 2009.
주상병 일치도에 관한 연구 -1개 중소병원을 중심으로-
서영숙1, 김유미2, 남문희3, 강성홍4, 임지혜5
1인제대학교 대학원 보건행정학과
3부산성모병원 간호부
4인제대학교 보건행정학부
5동주대학 보건의료행정과
A Study on the agreement of Principal Diagnosis
Young-Suk Seo1, Yoo-Mi Kim2, Moon-Hee Nam3, Sung-Hong Kang4, Ji-Hye Lim5
1Graduate School of Public Health, Inje University
2Korea Health Industry Development Institute
3Department of Nursing Busan St. Mary's Medical Center
4Department of Health Care Administration, Inje University
5Department of Health and Medical administration, Dongju College
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.
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.
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.
Key words Principal diagnosis;medical record;coding;


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