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PubMed · 8755383

Improving coded data entry by an electronic patient record system.

J H Hohnloser·F Puerner·H Soltanian
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Abstract

Data are presented on the use of a browsing and encoding utility to improve coded data entry for an electronic patient record system. Traditional and computerized discharge summaries were compared: during three phases of coding ICD-9 diagnoses phase I, no coding; phase II, manual coding, and phase III, computerized semiautomatic coding. Our data indicate that (1) only 50% of all diagnoses in a discharge summary are encoded manually; (2) using a computerized browsing and encoding utility this percentage may increase by 64%; (3) when forced to encode manually, users may "shift" as much as 84% of relevant diagnoses from the appropriate coding section to other sections thereby "bypassing" the need to encode, this was reduced by up to 41% with the computerized approach, and (4) computerized encoding can improve completeness of data encoding, from 46 to 100%. We conclude that the use of a computerized browsing and encoding tool can increase data quality and the percentage of documented data. Mechanisms bypassing the need to code can be avoided.

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Data CollectionDiseaseDocumentationElectronic Data ProcessingHumansMedical History TakingMedical Records Systems, ComputerizedPatient DischargeQuality Assurance, Health CareSoftwareComparative StudyJournal Article

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J H Hohnloser, F Puerner, H Soltanian. 1996. Improving coded data entry by an electronic patient record system.. https://pubmed.ncbi.nlm.nih.gov/8755383/

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