Resumo

POSADA-AREVALO, Sergio Eduardo; BROCA-SANCHEZ, Mariana  e  ZAVALA-GONZALEZ, Marco Antonio. Quality of the register of medical diagnosis and subsequent coding in a second level hospital from Tabasco, Mexico, 2009. Medicas UIS [online]. 2015, vol.28, n.2, pp.187-194. ISSN 0121-0319.

Objective: To know the proportion of properly coded diagnosis according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, as a result of successful registration by the treating physician in outpatient daily reports in a second level hospital from Cardenas, Tabasco, Mexico, in 2009. Materials and Methods: A cross-sectional research was conducted in health systems, in which, from 450 outpatient registration forms (N = 450) generated during April to October 2009 in a general hospital of social security from Tabasco, Mexico, it was taken a probability sample of 39 forms (p = 0.8, Z = 1.645, d = 0.1), from which were excluded two broken and one dirty, being studied 36 forms (n = 36) which included 372 diagnoses registered, whose register quality and consistency with the names of diseases according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, were reviewed, and it was described their impact on the quality of the coding, on behalf the Statistic Department. Results: From 372 studied records, 50% showed mistake, being the most common the use of abbreviations or acronyms (37.4%). Only 100 (26.9%) of the records included presented consistency according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, observing that in 131 cases (35.2%) a successful coding was achieved. Conclusions: 65% of morbidity reported by the Statistical Department does not correspond to reality, leading to management decisions with poor quality information. MÉD.UIS. 2015;28(2):187-94

Palavras-chave : Morbidity; International Classification of Diseases; Medical Records Department; Hospital; Documentation.

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