IMPROVING CODED DATA-ENTRY BY AN ELECTRONIC PATIENT RECORD SYSTEM

Data are presented on the use of a browsing and encoding utility to im prove coded data entry for an electronic patient record system. Tradit ional 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 in dicate that (1) only 50% of all diagnoses in a discharge summary are e ncoded manually; (2) using a computerized browsing and encoding utilit y this percentage may increase by 64%; (3) when forced to encode manua lly, users may ''shift'' as much as 84% of relevant diagnoses from the appropriate coding section to other sections thereby ''bypassing'' th e need to encode, this was reduced by up to 41% with the computerized approach, and (4) computerized encoding can improve completeness of da ta encoding, from 46 to 100%. We conclude that the use of a computeriz ed browsing and encoding tool can increase data quality and the percen tage of documented data. Mechanisms bypassing the need to code can be avoided.