Computer Applications in Medical Care. Computer Systems in Hospitals. Medical Records and Quality Assurance: Validation Techniques for Medical Data

摘要

A medical data base is only as good as the data it contains, and the process of collecting medical information and converting it to machine-readable form is fraught with opportunities for error. An analysis of the regularities in medical data permits the development of validity and reasonableness checks which can be automated. We examine the regularities to be found in common elements of medical data and suggest checks based on these regularities. Particular attention is given to constructing checks which lend themselves to automation.We draw on experiences from the medical records department of a 1,000 bed teaching hospital and three multi-hospital quality-of-care review projects.