Hohnloser J H, Pürner F, Kadlec P
Med. Klinik, Klinikum Innenstadt, Ludwig-Maximilians-Universität, München, Germany.
Int J Clin Monit Comput. 1995;12(3):141-5. doi: 10.1007/BF02332688.
In clinical routine there is a growing need to encode medical concepts with available standard coding systems. The coding process can be time consuming and may significantly add to daily paperwork, particularly regarding patients with multiple diagnoses and in busy clinical environments with a high turnover of patients. We have developed a generic computerised encoding tool--the PADS encoder--to ensure rapid, correct and complete coding of diagnoses in daily routine. The tool is integrated into an electronic patient record system (PADS, Patient Archiving & Documentation System) and takes full advantage of the user friendly Macintosh interface. The tool was tested in a controlled experiment by 18 clinicians who encoded a total of 666 medical concepts in each protocol (study protocol vs. control). The following positive findings were significantly associated with the use of the computerised coding tool: the number of correctly encoded medical concepts was higher (99.55% vs. 86.1%), coding errors were lower (0% vs. 10.81%), more modifier codes were encoded correctly (increase by up to 43%), less coding errors were made (decrease by up to 43%), the overall rate of correctly encoded and complete main and modifier codes was increased by 31.27% (97.29% vs. 66.02%), coding time was reduced by 50%. This paper presents data to suggest that a computerised coding tool can produce more complete data of higher quality and can save time compared with the traditional approach to encode medical concepts.
在临床日常工作中，使用现有的标准编码系统对医学概念进行编码的需求日益增长。编码过程可能很耗时，并且可能会显著增加日常文书工作，特别是对于有多种诊断的患者以及患者周转量大的繁忙临床环境。我们开发了一种通用的计算机化编码工具——PADS编码器，以确保在日常工作中对诊断进行快速、正确和完整的编码。该工具集成到一个电子病历系统（PADS，患者存档与文档系统）中，并充分利用了用户友好的Macintosh界面。18名临床医生在一项对照实验中对该工具进行了测试，他们在每个方案（研究方案与对照）中总共编码了666个医学概念。以下积极结果与使用计算机化编码工具显著相关：正确编码的医学概念数量更高（99.55%对86.1%），编码错误更低（0%对10.81%），更多的修饰码被正确编码（增加高达43%），编码错误减少（减少高达43%），正确编码且完整的主码和修饰码的总体比率提高了31.27%（97.29%对66.02%），编码时间减少了50%。本文提供的数据表明，与传统的医学概念编码方法相比，计算机化编码工具可以产生质量更高、更完整的数据，并且可以节省时间。
