A Study on the agreement of Principal Diagnosis

Seo, Young-Suk; Kim, Yoo-Mi; Nam, Moon-Hee; Kang, Sung-Hong; Lim, Ji-Hye

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
²한국보건산업진흥원
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

Abstract

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.

Key words Principal diagnosis;medical record;coding;