乳房乳腺炎诊断码在电子医疗保健数据中的验证
Malini B DeSilva1, Elisabeth M Seburg1, Kirsten Ehresmann1
1From the Pregnancy and Child Health Research Center, HealthPartners Institute, Minneapolis, MN.
Epidemiology (Cambridge, Mass.)
|December 16, 2024
概括
哺乳期乳腺炎的电子健康记录诊断代码显示出良好的有效性. 将诊断代码与抗生素数据结合起来可以提高准确性,但可以减少哺乳期研究的病例数量.
科学领域:
- 医疗信息学 医疗信息学
- 产科和妇科 产科和妇科
- 公共卫生 公共卫生
背景情况:
- 电子健康记录 (EHR) 为哺乳研究提供未充分利用的数据.
- 国际疾病分类第10版临床修改 (ICD-10-CM) 哺乳期乳腺炎代码的准确性需要验证.
研究的目的:
- 评估ICD-10-CM诊断代码的有效性,以识别乳房乳腺炎在EHR数据中的有效性.
- 为了确定这些代码的正预测值 (PPV),单独和与抗生素分发数据一起.
主要方法:
- 从三个医疗保健系统 (2020年12月至2022年9月) 进行了EHR数据的回顾性审查.
- 纳入标准:活产,婴儿护理,以及记录的哺乳期.
- 使用ICD-10-CM代码 (N61.0,O91.2) 来识别疑似病例,并审查图表以确认"可能"或"可能"的哺乳乳乳腺炎定义.
主要成果:
- 在19,660名符合条件的患者中,5.2%的人有相关的诊断代码,3.9%的人有代码加上抗生素发行.
- 对119名患者的图表审查显示,可能的PPV为76%,可能或可能的乳房乳腺炎为97%.
- 对于服用抗生素的患者 (n=87),PPV增加到80%的可能和100%的可能或可能的乳房乳腺炎.
结论:
- 仅ICD-10-CM诊断代码就显示了乳房乳腺炎的良好积极预测价值.
- 纳入抗生素分发数据可以增强PPV,但可以减少确诊病例的数量.
- 在未来的研究中,EHR诊断代码可能是唯一可行的选择,用于识别哺乳期乳腺炎.
相关概念视频
Documentation of Nursing Diagnosis
1.2K
The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
1.2K
Formulating and Validating Nursing Diagnosis I
2.5K
A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent nursing interventions. The standardized terminologies of a nursing diagnosis help nurses identify and treat patients' problems. Every electronic health record that uses nursing diagnosis must employ standard diagnostic terminology. Developing an efficient, individualized care plan begins with accurate nursing diagnoses.
There are thirteen domains...
There are thirteen domains...
2.5K
Data Validation
4.9K
Data validation is an essential part of a comprehensive assessment. Validation is confirming or verifying and opening the door to gathering more assessment data as it clarifies vague or unclear data. The process of checking and verifying the collected information is called data validation. The primary purpose of data validation is to ensure data is as free from error, bias, and misinterpretation as possible.
Nursing assessment guides are generally based on holistic models rather than medical...
Nursing assessment guides are generally based on holistic models rather than medical...
4.9K
Methods of Documentation VII: EMR
824
Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
824
Formulating and Validating Nursing Diagnosis II
2.6K
Nursing diagnoses represent a problem validated by major defining characteristics. There are four categories of nursing diagnoses: problem-focused, risk, health promotion or wellness, and syndrome. The anatomy of a nursing diagnosis includes three components: problem statement or diagnostic label, defining characteristics, and related factors.
Risk nursing diagnoses represent clinical judgments of an individual, family, or community more vulnerable to developing the health problem than others...
Risk nursing diagnoses represent clinical judgments of an individual, family, or community more vulnerable to developing the health problem than others...
2.6K
Methods of Documentation V: CBE
878
Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
878


