Adnan, Mohd Syafwan
(2018)
A study of diagnosis discrepancy between admission and discharge in Hospital Universiti Sains Malaysia.
Masters thesis, Universiti Sains Malaysia.
Abstract
Background: The accuracy of Emergency Department (ED) doctors in making a provisional
diagnosis is crucial as it has direct impact on the patient treatment, safety, length of stay and
cost of treatment. The study of the accuracy of the provisional diagnosis made by ED to
compare with the discharge diagnosis is scarce in its availability and most results vary with
different continents. This study was conducted to evaluate the accuracy of the diagnosis made
by ED doctors in Hospital Universiti Sains Malaysia (HUSM) and the factors contributed to
the discrepancy.
Methods: This was a retrospective cross-sectional study in which medical records of patient
admitted to hospital USM within Mei 2016 until December 2017 were selected using simple
random sampling methods. The folders were then reviewed and the association within the
categorized diagnosis accuracy was analysed using the ICD-10 classification. The sample
size was 180 cases and cases was divided into two main categories. The factors associated
with the unmatched diagnosis from both, patients and provider were then measured using
multiple logistic regressions.
Results: Hospital USM Emergency department had 84.4 percent of matched diagnosis with
15.56 percent of unmatched diagnosis. The odds of having unmatched diagnosis in patients
from green zone are 4.2 times higher compared to the red zone.
Conclusions: Hospital USM Emergency department had high diagnostic accuracy as
compared to the unmatched diagnosis.
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