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April 22, 1992

Accuracy in Recorded Diagnoses

Author Affiliations

From the Health Standards and Quality Bureau, Health Care Financing Administration, Baltimore, Md.

JAMA. 1992;267(16):2238-2239. doi:10.1001/jama.1992.03480160096043

Although making accurate diagnoses is a critical clinical skill, putting accurate diagnoses on the face sheet of a medical record does not have the same priority for most physicians. Even those who see recording a correct principal diagnosis as an important part of good clinical thinking are unlikely to be perfectionists regarding additional diagnoses because it is hard to see that they will have any effect on patient care.

See also p 2197.

In the last few years, however, major journals have published a growing number of articles in which recorded additional diagnoses play an important part in analysis, either to establish a clinical point or to assess additional diagnoses as a measure of clinical severity of illness. Investigators seek to secure information from additional diagnoses, which would otherwise require costly manual abstraction, about the occurrence of adverse events and the risk of outcomes such as death. In addition, hospital