Schütz P, Deimel D, Dusberger T
Orthopädische Universitätsklinik Mannheim.
Orthopade. 1999 Mar;28(3):270-6.
With the German health care restructuring legislation ("Gesundheitsstrukturgesetz") the coding of diagnoses and operations according to ICD-9 and ICPM (OPS-301) was introduced for budget assignment ("Fallpauschalen/Sonderentgelte").
Application of the structured coding system "do it" in orthopedics and traumatology in combination with a surgical documentation system. Results of 8,664 documented operative cases within three years.
In total, 11,854 ICD-9 or ICD-10 and 20,178 ICPM (OPS-301) were coded. 2,914 "Fallpauschalen" and/or 3,456 "Sonderentgelte" were found. The System achieved high acceptance due to its userfriendliness and simple functionality.
In comparison with text- or thesaurus-based coding systems the "do it" coding system does not require any knowledge of the ICD or ICPM (OPS-301). It can be adapted to individual clinical requirements by implementing frequent diagnoses and individual therapy concepts. In combination with a medical information system the coding system can be integrated seamlessly into routine documentation.
随着德国医疗保健结构调整立法（“《健康结构法》”）的实施，为了进行预算分配（“病例包干/特殊费用”），引入了根据国际疾病分类第9版（ICD - 9）和国际疾病分类手术操作编码（ICPM，即德国手术操作编码系统OPS - 301）对诊断和手术进行编码。
在骨科和创伤学中应用结构化编码系统“do it”并结合手术记录系统。记录了三年内8664例手术病例的结果。
总共对11854个ICD - 9或ICD - 10编码以及20178个ICPM（OPS - 301）编码进行了编码。发现了2914个“病例包干费用”和/或3456个“特殊费用”。该系统因其用户友好性和简单的功能而获得了高度认可。
与基于文本或词库的编码系统相比，“do it”编码系统不需要任何关于ICD或ICPM（OPS - 301）的知识。通过纳入常见诊断和个体化治疗概念，它可以适应个体临床需求。与医疗信息系统相结合，该编码系统可以无缝集成到日常记录中。
