title: Positive efficiency findings using computer assisted ICD-encoding: 3.5 years of experience with the computerized patient record system PADS (Patient Archiving & Documentation System).
abstract: In daily routine there is a major discrepancy between what physicians do and what they document. From a medical information processing point of view amongst the more important functions physicians perform in their daily routine is the encoding of diagnoses using a standard vocabulary such as ICD-9. This paper presents evidence that through the use of the ICD-encoding module of a computerized patient record system (PADS, Patient Archiving and Documentation System) user compliance can be improved. "Bypassing" mechanisms can be partly reversed (up to 43%), more coded diagnoses are documented (by 51%) and those diagnoses documented are more complete (increase by 57%).
authors.affiliation: University of Munich, Germany.
authors.forename: J H
authors.initials: JH
authors.lastname: Hohnloser
authors.forename: H
authors.initials: H
authors.lastname: Soltanian
mesh_terms: D005858:Germany; D006785:Hospitals, University; D016347:Medical Records Systems, Computerized; D013358:Subject Headings