RESUMO
OBJECTIVE: To find the reliability of the coding of diagnoses in the doctor's note in this computer system and to analyse where there are most discrepancies. DESIGN: An observational study. The concordance between the reason for consultation, codified by an external assessor, and the coding of the main diagnosis. SETTING: Health Districts 17 (Murcia/Barrio del Carmen) and 66 (Molina de Segura/La Ribera) in the Autonomous Community of Murcia. PATIENTS: A sub-sample of 228 consultations, belonging to a larger study of 1,904 general medical consultations (total: 98,768 consultations). MEASUREMENTS AND MAIN RESULTS: There were discrepancies between the coding of the reason for consultation and the diagnosis in 23% of the consultations recorded. The reason for consultation was not correctly recorded in 12.3%. The diagnostic group or section with the highest level of agreement was number XVIII or the supplementary section; and with the least agreement in XVII (injuries and adverse side-effects) and Number V covering mental disorders. CONCLUSIONS: Quality control of information and its validation enables errors and problems in the systems to be identified and corrected. This study points to the need to improve the filling-out of the reason for consultation and activity carried out, in order to obtain afterwards a more reliable coding of the diagnosis.
