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PubMed · 10273964

Informed consent.

D R Gregory
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Abstract

Because the subject of informed consent is such a major medicolegal issue, it is important that every physician understand exactly what the law means by the word "informed." In this article, the author presents a brief history of how the law came into being and outlines the essential elements that the patient must be told in order for you to stay within the law.

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Forms and Records ControlHumansInformed ConsentUnited StatesJournal Article

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D R Gregory. 1985. Informed consent.. https://pubmed.ncbi.nlm.nih.gov/10273964/

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PubMed2000

Do we do what they say we do? coding errors in urology.

OBJECTIVE: To determine the accuracy of routine data coding in a large multispeciality urological unit. Materials and methods From the clinical records, the diagnosis and procedure codes were ascribed to 106 finished consultant episodes (FCEs) in urology, by two urological trainees. The codes were compared with those ascribed by professional hospital coders (and of which the trainees were unaware) from information written on the audit form by junior medical staff. Where there were discrepancies in codes an error was recorded and the stage in the coding process in which it occurred was determined. RESULTS: Forty-eight coding errors were found in 38 of the 106 (36%) FCEs; 34 (71%) were caused by inaccurate coding and 14 (29%) were the result of the incorrect completion of audit forms. CONCLUSION: The clinical codes generated from the authors' department do not accurately reflect the clinical practice. If coding errors of this magnitude are typical of urology units in general, the concept of hospital performance tables (which will be generated using routine clinical data) is untenable unless data recording is given higher priority.

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