[DocuMed--a personal computer program system for basic documentation and ICD statistics based on SNOMED].

Abstract

Of the different medical classification systems ICD only has endured on the long time, and through the german government regulations from 1985 (Bundespflegesatzordnung) ICD has become a must to all hospital departments for administration purposes. As a clinical and scientific system for encoding of diagnosis and treatment procedures ICD has been proved to be of minor suitability. SNOMED, a medical classification system derived from a pathological description of diseases seemed first to fulfill all the wishes clinicians have; but the very little use over the 12 years since its publication demonstrates its poor acceptance. This might be due to the time consuming and lavish procedure of documentation in SNOMED, as entries have to be made in 7 categories. DocuMed, which is a microcomputer program and database on the one hand and a medical classification system on the other, seems to provide interesting features. For minimal documentation it only needs entries in the category of diagnosis, a term not present in SNOMED; for more detailed documentation requirements DocuMed provides similar categories as SNOMED with references to the latter and to ICD.