Methods Inf Med 1996; 35(02): 108-111
DOI: 10.1055/s-0038-1634644
Original Article
Schattauer GmbH

Improving Coded Data Entry by an Electronic Patient Record System

J. H. Hohnloser
1   Med. Klinik, Klinikum Innenstadt Ludwig-Maximilians-Universiäit München, München, Germany
,
F. Puerner
1   Med. Klinik, Klinikum Innenstadt Ludwig-Maximilians-Universiäit München, München, Germany
,
H. Soltanian
1   Med. Klinik, Klinikum Innenstadt Ludwig-Maximilians-Universiäit München, München, Germany
› Author Affiliations
Further Information

Publication History

Publication Date:
14 February 2018 (online)

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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.