Comparison of the quality of patient data collected by hospital and departmental computer systems.

Health trends Pub Date : 1993-01-01
K Walshe, N Harrison, M Renshaw
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Abstract

The quality of patient data routinely collected in hospitals is rarely assessed, though by repute it may often be incomplete and inaccurate. To explore their completeness and accuracy, patient data separately collected by a hospital Patient Administration System (PAS) and by a departmental Clinical Information System (CIS) used by clinicians were compared. The results indicate that, although both systems appear to record reliably demographic and administrative data, PAS data are more complete than CIS data. Moreover clinicians and medical records staff seem to use classifications of diagnoses and procedures in profoundly different ways. More attention should be paid to the need to assess and improve data quality. The development of a shared database, used and validated by medical records staff and clinicians alike, may be the best way to achieve this.

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比较医院和部门计算机系统收集的患者数据的质量。
医院例行收集的病人数据的质量很少得到评估,尽管人们认为这些数据可能经常不完整和不准确。为了探讨其完整性和准确性,比较了由医院患者管理系统(PAS)和临床医生使用的部门临床信息系统(CIS)分别收集的患者数据。结果表明,虽然这两个系统似乎都可靠地记录了人口和行政数据,但PAS数据比CIS数据更完整。此外,临床医生和医疗记录人员似乎以截然不同的方式使用诊断和程序分类。应当更加注意评估和改进数据质量的必要性。开发一个共享数据库,由医疗记录工作人员和临床医生共同使用和验证,可能是实现这一目标的最佳途径。
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