Physician and Coding Errors in Patient Records

Susan S. Lloyd, John Peter Rissing

Research output: Contribution to journalArticle

199 Citations (Scopus)

Abstract

The Veterans Administration's discharge abstract system was studied to identify error frequency, source, and effect in five Veterans Administration hospitals. We reviewed 1,829 medical records from 21 services for concordance with the abstract; sampling provided 95% confidence for each service. Of these records, 1,499 (82%) differed from the abstract in at least one item. Of 20,260 items, 4,360 (22%) were incorrect, with three error sources: physician (62%), coding (35%), and keypunch (3%). We projected 2.14 physician and 0.81 coding errors in the average abstract. Eighty-nine percent of projected physician errors were failures to report a procedure or diagnosis. Coding was subjective and errors were synergistic with physician errors. We projected that correction of errors would change 19% of the records for diagnosis-related group purposes and substantially increase future resource allocation. This effect varied considerably by service.

Original languageEnglish (US)
Pages (from-to)1330-1336
Number of pages7
JournalJAMA: The Journal of the American Medical Association
Volume254
Issue number10
DOIs
StatePublished - Sep 13 1985

Fingerprint

Physicians
United States Department of Veterans Affairs
Research Design
Veterans Hospitals
Resource Allocation
Diagnosis-Related Groups
Medical Records

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Physician and Coding Errors in Patient Records. / Lloyd, Susan S.; Rissing, John Peter.

In: JAMA: The Journal of the American Medical Association, Vol. 254, No. 10, 13.09.1985, p. 1330-1336.

Research output: Contribution to journalArticle

@article{ff3c993e10cf4fa5bab9da1911655386,
title = "Physician and Coding Errors in Patient Records",
abstract = "The Veterans Administration's discharge abstract system was studied to identify error frequency, source, and effect in five Veterans Administration hospitals. We reviewed 1,829 medical records from 21 services for concordance with the abstract; sampling provided 95{\%} confidence for each service. Of these records, 1,499 (82{\%}) differed from the abstract in at least one item. Of 20,260 items, 4,360 (22{\%}) were incorrect, with three error sources: physician (62{\%}), coding (35{\%}), and keypunch (3{\%}). We projected 2.14 physician and 0.81 coding errors in the average abstract. Eighty-nine percent of projected physician errors were failures to report a procedure or diagnosis. Coding was subjective and errors were synergistic with physician errors. We projected that correction of errors would change 19{\%} of the records for diagnosis-related group purposes and substantially increase future resource allocation. This effect varied considerably by service.",
author = "Lloyd, {Susan S.} and Rissing, {John Peter}",
year = "1985",
month = "9",
day = "13",
doi = "10.1001/jama.1985.03360100080018",
language = "English (US)",
volume = "254",
pages = "1330--1336",
journal = "JAMA - Journal of the American Medical Association",
issn = "0002-9955",
publisher = "American Medical Association",
number = "10",

}

TY - JOUR

T1 - Physician and Coding Errors in Patient Records

AU - Lloyd, Susan S.

AU - Rissing, John Peter

PY - 1985/9/13

Y1 - 1985/9/13

N2 - The Veterans Administration's discharge abstract system was studied to identify error frequency, source, and effect in five Veterans Administration hospitals. We reviewed 1,829 medical records from 21 services for concordance with the abstract; sampling provided 95% confidence for each service. Of these records, 1,499 (82%) differed from the abstract in at least one item. Of 20,260 items, 4,360 (22%) were incorrect, with three error sources: physician (62%), coding (35%), and keypunch (3%). We projected 2.14 physician and 0.81 coding errors in the average abstract. Eighty-nine percent of projected physician errors were failures to report a procedure or diagnosis. Coding was subjective and errors were synergistic with physician errors. We projected that correction of errors would change 19% of the records for diagnosis-related group purposes and substantially increase future resource allocation. This effect varied considerably by service.

AB - The Veterans Administration's discharge abstract system was studied to identify error frequency, source, and effect in five Veterans Administration hospitals. We reviewed 1,829 medical records from 21 services for concordance with the abstract; sampling provided 95% confidence for each service. Of these records, 1,499 (82%) differed from the abstract in at least one item. Of 20,260 items, 4,360 (22%) were incorrect, with three error sources: physician (62%), coding (35%), and keypunch (3%). We projected 2.14 physician and 0.81 coding errors in the average abstract. Eighty-nine percent of projected physician errors were failures to report a procedure or diagnosis. Coding was subjective and errors were synergistic with physician errors. We projected that correction of errors would change 19% of the records for diagnosis-related group purposes and substantially increase future resource allocation. This effect varied considerably by service.

UR - http://www.scopus.com/inward/record.url?scp=0021932124&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=0021932124&partnerID=8YFLogxK

U2 - 10.1001/jama.1985.03360100080018

DO - 10.1001/jama.1985.03360100080018

M3 - Article

VL - 254

SP - 1330

EP - 1336

JO - JAMA - Journal of the American Medical Association

JF - JAMA - Journal of the American Medical Association

SN - 0002-9955

IS - 10

ER -