Physician and coding errors in patient records

Abstract

The Veterans Administration''s [USA] discharge abstract system was studied to identify error frequency, source, and effect in five Veterans Administration hospitals. We reviewed 1829 medical records from 21 services for concordance with the abstract; sampling provided 95% confidence for each service. Of these records, 1499 (82%) differed from the abstract in at least one item. Of 20,260 items, 4360 (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 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.