Resumo

PESTANA DELGADO, Roberto; LLANOS ZAVALAGA LUIS, Luis Fernando; CABELLO MORALES, Emilio Andrés  e  LECCA GARCIA, Leonid. Concordance between medical diagnosis and informatics coding, considering ICD 10, at the Hospital Nacional Cayetano Heredia, Lima, Peru. Rev Med Hered [online]. 2005, vol.16, n.4, pp.239-245. ISSN 1018-130X.

Objective: To determine the compatibility of the diagnoses registered by the physicians under the International Statistical Classification of Diseases and Related Health Problems, tenth revision (ICD-10) and verify if they match with the code descriptions assigned by the data entry employees of the Statistics an Informatics Office (OEI). Materials and methods: A descriptive retrospective cross-sectional study has been done. We have taken 384 samples at random of outpatients of the General and Department of Pediatric Specialized at Hospital Nacional Cayetano Heredia during January 2004. By registering diagnoses established by physicians we described the diagnoses features by a coding procedure under the International Statistical Classification of Diseases and Related Health Problems, tenth revision. (ICD-10). Results: Of the diagnoses registered by the physicians (533), 79.7% (425) were compatible with the ICD-10 and 91.4% (487) were coded by the statistic personnel of the HNCH. The concordance between the medical diagnosis and the coding process was 49.2%, ascending to 53.8% when only considered the coded diagnostic terms. Conclusions: At the end of the coding process at the outpatient Service of General and Department of Pediatric Specialized at Hospital Nacional Cayetano Heredia, 50.8% of the quality (validity) of original medical information gets lost. It is recommended to implement mechanisms that allow improving the quality of the registered information through training personnel involved in the coding process and compromise the physicians on an appropriate coding performance. (Rev Med Hered 2005;16:239-245).

Palavras-chave : Audit; medical audit; medical records; quality of registry.

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