Positive efficiency findings using computer assisted ICD-encoding: 3.5 years of experience with the computerized patient record system PADS (Patient Archiving & Documentation System).
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%).
Hohnloser
J H
JH
University of Munich, Germany.
Soltanian
H
H
D005858:Germany; D006785:Hospitals, University; D016347:Medical Records Systems, Computerized; D013358:Subject Headings