Agreement in Clinical Coding of Medical Records from Public Hospitals in Tucumán, 2014-2015

Abstract

INTRODUCTION: Morbidity and epidemiology information from medical records of hospitalization (IEH) influences health statistics and decisions. In 2013, 71.8% (61 002) IEH were initially coded in six medical record departments of public hospitals and then controlled or recoded by the Department of Health Services Statistics (DESS) in the province of Tucumán. OBJECTIVES: To evaluate the degree of agreement in clinical coding of diseases and surgical procedures between DESS and public hospitals from September 2014 to June 2015. METHODS: A concordance study in clinical coding was carried out, including stratified random sampling with proportional allocation according to hospital production. The degree of agreement was estimated with the Kappa statistic (K). RESULTS: A total of 2255 IEH were evaluated; 60.39% (1362) contained a second diagnosis and 54.01% (1218) a coded surgical procedure. The degree of agreement for coding between DESS and hospitals was: K=0.74 in primary diagnosis; K=0.61 in second diagnosis; and K=0.75 in surgical procedures. CONCLUSIONS: The degree of agreement for clinical coding in the IEH was good.