ABSTRACT
OBJECTIVES: This study examined the validity of the principal diagnoses on discharge summaries and coding assessments. METHODS: Data were collected from the National Health Security Office (NHSO) of Thailand in 2015. In total, 118,971 medical records were audited. The sample was drawn from government hospitals and private hospitals covered by the Universal Coverage Scheme in Thailand. Hospitals and cases were selected using NHSO criteria. The validity of the principal diagnoses listed in the “Summary and Coding Assessment” forms was established by comparing data from the discharge summaries with data obtained from medical record reviews, and additionally, by comparing data from the coding assessments with data in the computerized ICD (the data base used for reimbursement-purposes). RESULTS: The summary assessments had low sensitivities (7.3%–37.9%), high specificities (97.2%–99.8%), low positive predictive values (9.2%–60.7%), and high negative predictive values (95.9%–99.3%). The coding assessments had low sensitivities (31.1%–69.4%), high specificities (99.0%–99.9%), moderate positive predictive values (43.8%–89.0%), and high negative predictive values (97.3%–99.5%). The discharge summaries and codings often contained mistakes, particularly the categories “Endocrine, nutritional, and metabolic diseases”, “Symptoms, signs, and abnormal clinical and laboratory findings not elsewhere classified”, “Factors influencing health status and contact with health services”, and “Injury, poisoning, and certain other consequences of external causes”. CONCLUSIONS: The validity of the principal diagnoses on the summary and coding assessment forms was found to be low. The training of physicians and coders must be strengthened to improve the validity of discharge summaries and codings.