Facilitating Cross-National Comparisons of Indicators for Patient ...

DELSA/ELSA/WD/HTP(2008)1III. Details on medical documentationOECD Patient Safety Experts Subgroup HCQI ProjectIndicators for Patient Safety Questionnaire 20087 Coding rulesAre there any coding rules applied in your country to ensure that hospitaldischarge cases are abstracted in a uniform way?Yes No Unclearx x x8 Principal DiagnosisWhich definition of Principal Diagnosis (PDx) is used in your countryxabcdThe PDx is the condition established after review to be chiefly responsible for causing thehospitalisation.The PDx is related to that condition demanding the most resources during the hospital stay.Unclear, there is no uniform definition in use.Other (please describe)9 Secondary DiagnosisWhich definition of Secondary Diagnosis (SDx) is used in your countryxabcdA diagnosis qualifies for SDx documentation when additional resources (e.g. diagnostic means,therapeutic treatment, nursing, etc.) have been necessary. Diagnosis that related to an earlierepisode which have no bearing on the current hospital stay are to be excluded.Any diagnosis (e.g. information on medical history without actual treatment, comorbidity,complcations, etc.) related to that patient's condition qualifies as SDx.Unclear, there is no uniform definition in use.Other (please describe)10 External causes of morbidity and mortalityabcdThe use of ICD codes for external causes of morbidity and mortality is:optionalmandatoryof no useunclearx11How many data fields for secondary diagnosis documentation were available in the dataused for the calculation of indicators?12What is the mean number of secondary diagnoses per case in the data used forindicator calculation?13 How many data fields for procedure documentation were available in the data used forindicator calculation?225