Stručni rad

Correspondence of referral and discharge diagnoses in patients referred from primary care physicians and treated at the University Hospital for Infectious Diseases »Dr Fran Mihaljević« in Zagreb

J. Cindrić
E. Čeljuska-Tošev

Sažetak

We retrospectively analysed the correspondence of referral diagnoses from primary health care with discharge diagnoses of 2151 patients hospitalized at the University Hospital for Infectious Diseases »Dr. Fran Mihaljević« in the period from January 1 to December 31, 2004. All patients had a referral (»working«, »early«) diagnosis from their primary care physician and discharge (»major«, »first« or »final«) diagnosis when discharged from hospital. The International Classification of Diseases (ICD-10) was used in data analysis. As a source of information we used a computer database of hospitalized patients kept by the Medical Records Department of the University Hospital for Infectious Diseases »Dr. Fran Mihaljevi}« and Report on hospital medical activities in 2004. We evaluated the correspondence of referral and discharge diagnoses for each hospitalized patient individually. Obtained data were divided into three groups: a group of patients with corresponding referral and discharge diagnoses, those with non corresponding referral and discharge diagnoses and those in whom the correspondence of diagnoses was questionable. A total of 52 628 patients were examined at the Central Admissions Department of the Hospital Polyclinic, 7 474 of whom were hospitalized. Of these, 2 151 (28,78 %) had a referral from their primary care physician and thus presented the source of our analysis. Most frequent referral diagnoses were recorded under code R50 (Fever of unknown origin) in 538 (25,01 %) cases, then A09 (Diarrhoea and gastroenteritis of presumed infectious origin) in 349 (16,23 %) cases and J18 (Pneumonia, organism unspecified) in 118 (5,49 %) cases. On the other hand, the most common discharge diagnoses were N10 (Acute tubulo-interstitial nephritis), A09 (Diarrhoea and gastroenteritis of presumed infectious origin) and A46 (Erysipelas). The most common corresponding pairs of diagnoses, i.e. with identical referral and discharge diagnoses were A09 in 106 (10,98 %) and A46 in 90 (9,33 %) cases. In this paper the authors wanted to stress the importance of consistent classification of diseases, in primary care offices as well as in specialized clinics, since this is an important factor for proper medical records keeping, data management and analysis.

Ključne riječi

referral diagnosis; discharge diagnosis; correspondence; ICD-10; medical records

Hrčak ID:

12764

URI

https://hrcak.srce.hr/12764

Datum izdavanja:

30.9.2005.

Podaci na drugim jezicima: hrvatski

Posjeta: 4.692 *