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首页> 外文期刊>Orthopedics >The Implications of Inaccuracy: Comparison of Coding in Heterotopic Ossification and Associated Trauma
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The Implications of Inaccuracy: Comparison of Coding in Heterotopic Ossification and Associated Trauma

机译：不准确的含义：异位骨化和相关创伤中编码的比较

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摘要

Retrospective studies using large databases serve a major purpose in providing evidence in the current literature. However, the quality of medical coding is highly variable. This retrospective cohort study aimed to evaluate the documentation regarding the diagnosis of heterotopic ossification (HO) and the implications it may have for conducting retrospective research using electronic medical records (EMRs). A retrospective chart review using the EMR was performed to identify all patients with a diagnosis of HO within 7 university-affiliated hospital facilities. A limited data set request was conducted for all patients with HO-specific International Classification of Diseases, Ninth Revision (ICD-9) codes and additional nonspecific musculoskeletal codes to capture patients with HO who were improperly coded. A total of 522 patients were identified-26 patients with specific HO codes and 496 patients with nonspecific codes. Imaging and clinical notes were inspected for evidence and location of HO, and histories were reviewed for traumatic injury mechanism. Two-thirds of the patients with HO were discovered by reviewing miscellaneous musculoskeletal ICD-9 codes. Thirty-eight percent of the patients with an HO-specific ICD-9 code had no evidence of HO in their EMR. Thirty-three patients had a clinical history of a traumatic injury preceding HO formation, but only 16 of the 33 had documented ICD-9 codes for the injury. The utility of databases in retrospective research is dependent on the integrity of the coding. This study questions the use of retrospective reviews for patients with uncommon diagnoses and shows how painstaking verification may be necessary to ensure that research conclusions are based on accurate data.
机译：使用大型数据库的回顾性研究提供了在当前文献中提供证据的主要目的。但是，医学编码的质量是高度变化的。这种回顾性队列研究旨在评估关于异相型骨化诊断（HO）的诊断，以及利用电子医疗记录（EMRS）进行回顾性研究的影响。使用EMR的回顾性图表审查进行了识别所有患者在7位附属医院设施中诊断何。为所有疾病，第九次修订（ICD-9）代码和其他非特异性肌肉骨骼码进行了有限的数据集请求，以捕获不正确编码的HO患者。共鉴定了522名患者 - 26例特定的HO码和496名非特异性代码患者。检查HO的证据和位置的成像和临床票据，并对创伤损伤机制进行了审查历史。通过审查杂项肌肉骨骼ICD-9代码发现了三分之二的何患者。 HO专用ICD-9代码的38％的患者在他们的EMR中没有证据。三十三名患者有一个临床病史，前后的创伤损伤，但这33中只有16条记录了ICD-9伤害的代码。回顾性研究中数据库的效用取决于编码的完整性。本研究提出了对罕见诊断患者的回顾性评论的用途，并表明了可能需要术语，以确保研究结论是基于准确的数据。

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  • 来源
    《Orthopedics》 |2017年第4期|共5页
  • 作者

    Fury Matt; John Mitchell; Schexnayder Stuart; Molligan Harry; Lee Olivia; Krause Peter; Dasa Vinod;

  • 作者单位

    Louisiana State Univ Sch Med New Orleans LA 70112 USA;

    Louisiana State Univ Sch Med New Orleans LA 70112 USA;

    Louisiana State Univ Sch Med New Orleans LA 70112 USA;

    Louisiana State Univ Dept Orthopaed Surg 1542 Tulane Ave New Orleans LA 70112 USA;

    Louisiana State Univ Dept Orthopaed Surg 1542 Tulane Ave New Orleans LA 70112 USA;

    Louisiana State Univ Dept Orthopaed Surg 1542 Tulane Ave New Orleans LA 70112 USA;

    Louisiana State Univ Dept Orthopaed Surg 1542 Tulane Ave New Orleans LA 70112 USA;

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  • 原文格式 PDF
  • 正文语种 eng
  • 中图分类 骨科学（运动系疾病、矫形外科学）;
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