응급실 주진단명과 퇴원시 주진단명의 불일치도 조사 |
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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 |
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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 |
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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; |
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