The quality of patients’ data in medical documentation and statistical forms

The analysis of legal regulations on statistical and medical documentation has been performed and the quality of data was evaluated. The patients’ records and statistical forms of 31 patients discharged from a local hospital were studied. 127 initial diagnoses, 148 final diagnoses were stated in medical documentation, but only 73 of them were presented as ICD-10 codes. The identical initial and final diagnoses were noted in 57 cases. The average number of initial diagnoses per patient was 4.09±1.97 and final diagnoses – 4.77±1.81. The average number of diagnoses identical at admission and at discharge was 1.84±1.67. Statistical forms of the same patients contained only 93 diagnoses and 93 ICD-10 codes i.e. 55 diseases were not reported in statistical forms. The accordance in ICD-10 codes in medical and statistical documentation was noted only in 30 cases (out of 148 in clinical and out of 93 in statistical documentation). The diagnoses were identically written down in the medical and statistical forms only in 10 cases. All of that means poor completeness but high consistency of statistical data presented as MZ/Szp-11. In contrast, the medical data are of high completeness, validity and accuracy but of relatively low consistency. The further investigations are needed to reveal the most important reasons of discrepancies between medical and statistical data.