Tsopra, R, Wyatt, JC, Beirne, P et al. (6 more authors) (2019) Level of accuracy of diagnoses recorded in discharge summaries: A cohort study in three respiratory wards. Journal of Evaluation in Clinical Practice, 25 (1). pp. 36-43. ISSN 1356-1294
Abstract
Rationale: One of the key functions of the discharge summary is to convey accurate diagnostic description of patients. Inaccurate or missing diagnoses may result in a false clinical picture, inappropriate management, poor quality of care, and a higher risk of re‐admission. While several studies have investigated the presence or absence of diagnoses within discharge summaries, there are very few published studies assessing the accuracy of these diagnoses. The aim of this study was to measure the accuracy of diagnoses recorded in sample summaries, and to determine if it was correlated with the type of diagnoses (eg, “respiratory” diagnoses), the number of diagnoses, or the length of patient stay.
Methods: A prospective cohort study was conducted in three respiratory wards in a large UK NHS Teaching Hospital. We determined the reference list of diagnoses (the closest to the true state of the patient based on consultant knowledge, patient records, and laboratory investigations) for comparison with the diagnoses recorded in a discharge summary. To enable objective comparison, all patient diagnoses were encoded using a standardized terminology (ICD‐10). Inaccuracy of the primary diagnosis alone and all diagnoses in discharge summaries was measured and then correlated with type of diseases, number of diagnoses, and length of patient stay.
Results: A total of 107 of 110 consecutive discharge summaries were analysed. The mean inaccuracy rate per discharge summary was 55% [95% CI 52 to 58%]. Primary diagnoses were wrong, inaccurate, missing, or mis‐recorded as a secondary diagnosis in half the summaries. The inaccuracy rate was correlated with the type of disease but not with number of diagnoses nor length of patient stay.
Conclusion: Our study showed that diagnoses were not accurately recorded in discharge summaries, highlighting the need to measure and improve discharge summary quality.
Metadata
Item Type: | Article |
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Authors/Creators: |
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Copyright, Publisher and Additional Information: | © 2018 John Wiley & Sons, Ltd. This is the peer reviewed version of the following article: Tsopra R, Wyatt JC, Beirne P, et al. Level of accuracy of diagnoses recorded in discharge summaries: A cohort study in three respiratory wards. J Eval Clin Pract. 2018;1–8, which has been published in final form at https://doi.org/doi.org/10.1111/jep.13020. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving. Uploaded in accordance with the publisher's self-archiving policy. |
Keywords: | coding; data accuracy; diagnosis; ICD 10 coding; patient discharge summaries; quality of health care |
Dates: |
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Institution: | The University of Leeds |
Academic Units: | The University of Leeds > Faculty of Medicine and Health (Leeds) > Institute of Molecular Medicine (LIMM) (Leeds) > Section of Translational Medicine (Leeds) |
Depositing User: | Symplectic Publications |
Date Deposited: | 25 Oct 2018 15:31 |
Last Modified: | 14 Aug 2019 00:43 |
Status: | Published |
Publisher: | Wiley |
Identification Number: | 10.1111/jep.13020 |
Open Archives Initiative ID (OAI ID): | oai:eprints.whiterose.ac.uk:137734 |