Kvaliteten af diagnose- og procedurekodning i Ortopædkirurgi Nordjylland

Introduction: When the aim is for high quality, efficiency and a balanced allocation of resources in health services, there is a constant demand for optimisation of the quality of registration regarding diagnosis, treatment and DRG-values (DRG = Diagnosis Related Groups). Since the mid-nineties the DRG-system has been used to shed light on productivity in Danish hospitals. This study investigates the quality of registrations after the introduction of an organization for registrations in the county of Northern Jutland. Material and methods: The registrations from 554 orthopaedic patients, both in-patient and day case surgery, during a two-week period, were scrutinised critically and changed as appropiate, based on a thorough examination of the medical records. Results: In 37% of the courses registrations were found insufficient or incorrect. In 27% of the cases there was a need for a change in either the diagnosis taken action on, a secondary diagnosis or the treatment registration. 10% had two or three changes. In 11% of the courses of treatment the DRG-value was changed. On average DKK 974 were added, constituing in total only 0.4% of the total DRG-value. But single variations from deductions of DKK 56,000 to an addition of DKK 39,000 were observed. The gravest mistakes are elucidated. Conclusion: Locally, there is a need for continuous instruction of both doctors and secretaries regarding correct registration of diagnosis and treatment as well as an improvement of the registration facilities. On a national basis more precise recommendations are required within the medical specialist areas in order to secure an unambiguous registration.