Multi-site medical record review for validation of intentional self-harm coding in emergency departments

Table 1 Setting and other study characteristics: medical record review of intentional self-harm treated in EDs

	Maryland	Colorado	Massachusetts
	Large academic hospital	All acute care hospitals in the state	All acute care hospitals in the state
Number of hospital EDs in the study (in the sampling frame)	1	80^a	71
Number of records in random sample	234	260	400
% of state population covered by hospital(s) (catchment area)	15%	100%	100%
Dates of the ED visits in the billing data set	Jan 2018–Dec 2019	Jan 2019–Dec 2019	Oct 2017–Sep 2018
Number of diagnosis fields in the ED billing data set	32	30 + 3 cause fields	30 + 1 cause field
Medical record reviewer	10 clinical researchers	1 professional coder	3 professional coders
Data source	Electronic medical record	ED report and EMS transport^b	Full ER record^c

ED emergency department, EMS emergency medical services, ER emergency room
^a80 of 81 reported in 2019. The ED visits at the non-reporting hospital with two ED locations accounted for less than 0.001% of all Colorado ED visits in 2019
^bAlso requested: face sheet, triage reports, toxicology and laboratory reports, history and physical, social worker notes, physician notes, psychiatry notes, consultations, discharge summary, and ICD-10-CM codes
^cFull ER record including nursing and physician progress notes, EMS reports, behavioral and psychiatric consults, and social service notes

ISSN: 2197-1714