Accuracy in recorded diagnoses
Article Abstract:
Physicians should record second diagnoses accurately in patients' medical and hospital records. Second diagnoses that are recorded may help physicians evaluate and treat a patient's illness. A research study found that patients suffering from stroke, heart attack, pneumonia or congestive heart failure who had a second diagnosis of hypertension, chest pain or heart valve disease had higher survival rates than those without these secondary conditions noted on charts. This increase in survival may have a medical explanation, but many physicians are doubtful about this theory. The decision to record second diagnoses on patients' medical records may be difficult because for several reasons. Rules for recording additional diagnoses are broad; rules for using clinical codes to record secondary conditions often are unclear, and physicians are afraid of the legal and ethical implications of recording many secondary conditions. To improve the quality of medical records, rules for recording secondary conditions and using clinical codes in medical records need to be redefined and clarified.
Publication Name: JAMA, The Journal of the American Medical Association
Subject: Health
ISSN: 0098-7484
Year: 1992
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The 1988 Bethesda system for reporting cervical/vaginal cytological diagnoses. (National Cancer Institute Workshop). (Including list of workshop participants)
Article Abstract:
The mortality rate of cervical cancer (cancer of the neck of the uterus) has significantly declined during the last 40 years, in part because of the use of the 'pap test.' However, recent criticism of the test concerning quality control issues, including the means of classifying the tissue obtained, has caused a reevaluation. An additional area of concern is the sometimes ambiguous terminology used to convey the laboratory information to the practicing physician. A workshop held by the Division of Cancer Prevention and Control, National Cancer Institute addressed this issue. Participants reviewed existing terminology and recommended methods of improving reporting. The participants concluded that the cytopathology report is a medical consultation, the Papanicolau classification for reporting consultations is not acceptable and the Bethesda System should serve as a guideline for cytopathology reports of cervical-vaginal specimens. The Bethesda System is discussed in detail.
Publication Name: JAMA, The Journal of the American Medical Association
Subject: Health
ISSN: 0098-7484
Year: 1989
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