ACCURACY OF MEDICAL RECORDS IN HIP FRACTURE

OBJECTIVE: To determine the accuracy of diagnoses and procedure codes in medical records for hip fracture patients. DESIGN: A validation sam ple of hip fracture medical records was used to compare the facesheet data with progress notes, operative reports, and discharge summaries f or patients in a prospective study of functional recovery. SETTING: Ei ght Baltimore hospitals with the highest volume of older hip fracture patients. PATIENTS: Study subjects were 343 community-dwelling patient s, 65 years of age and older, admitted to one of eight Baltimore hospi tals between January 1990 and June 1991 with a diagnosis of hip fractu re. MAIN OUTCOME MEASURES: Facesheet diagnosis codes were compared wit h admitting notes, discharge summary, and/or progress notes. The abstr acted surgical procedure was compared with postoperative radiographs. RESULTS: Excess coding of diagnoses on the hospital facesheet was evid ent in 12% of charts. In 17% of charts, a complication identified in t he chart was not coded on tine facesheet. More complications with low severity were omitted. Agreement between the abstractor's procedure re view and radiograph readings for arthroplasty was 84%. In 15% of patie nts, the abstractor coded total arthroplasty when hemiarthroplasty was done. CONCLUSIONS: Discrepancy between the hospital facesheet and the medical record and between the abstracted surgical procedure and radi ographs was found for hip fracture patients. This may make findings fr om health outcomes research relying on administrative databases uncert ain and reimbursement inaccurate.