Improving the quality of the coding of primary diagnosis in standardized discharge summaries.
We propose to design and test an information-processing model to participate in appraising the quality and the consistency of the coding, for billing, of Standardized Discharge Summaries (SDSs). We designed a model using both symbolic knowledge extracted from the NLM's UMLS and statistical knowledge. The aim is to retrieve from the ICD-10 terms recorded in a SDS the Principal Diagnosis (PD) at the time of coding. In 90% of cases the PD was retrieved 1st or 2nd in SDS including three ICD-10 codes or more. This model could contribute as part of an automated quality control process in a hospital information system by checking consistency in coded SDSs and improve the income of the hospital.
Avillach
Paul
P
LERTIM, Faculté de Médecine, Université de la Méditerranée, 27 Bd Jean Moulin, F-13385 Marseille Cedex 5, France. Paul.Avillach@isped.u-bordeaux2.fr
Joubert
Michel
M
Fieschi
Marius
M
D003266:Continuity of Patient Care / Q000458:organization & administration; D006739:Hospital Administration; D006801:Humans; D007256:Information Systems / Q000458:organization & administration; D038801:International Classification of Diseases; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D010351:Patient Discharge; D011787:Quality of Health Care / Q000458:organization & administration*; D015203:Reproducibility of Results; D009626:Terminology as Topic; D018875:Vocabulary, Controlled