Storage and retrieval of coded patient diagnoses and data on a clinical laboratory computer system.
A system has been developed which allows for easy storage and retrieval of patient diagnoses using ICD-9-CM codes. Entered codes are automatically interpreted by the computer and then both the code and the interpretation are stored as in integral part of the patient record. Teaching clinicians may use an automated, keyword-search algorithm to display the code for a diagnosis of interest and then use that code to find any hospitalized patient with such a primary or secondary diagnosis. Entered diagnoses automatically appear on worksheets in the clinical laboratory. Retrospective studies also may be performed whenever a pathologist wants to compare diagnoses with laboratory results.
D019411:Clinical Laboratory Techniques; D003201:Computers; D003626:Data Display; D006801:Humans; D007256:Information Systems; D008499:Medical Records