POSITIVE EFFICIENCY FINDINGS USING COMPUTER-ASSISTED ICD-ENCODING - 3,5 YEARS OF EXPERIENCE WITH THE COMPUTERIZED PATIENT RECORD SYSTEM PADS (PATIENT ARCHIVING AND DOCUMENTATION SYSTEM)

In daily routine there is a major discrepancy between what physicians do and what they document. From a medical information processing point of view amongst the more important functions physicians perform in th eir daily routine is the encoding of diagnoses using a standard vocabu lary such as ICD-9. This paper presents evidence that through the use of the ICD-encoding module of a computerized patient record system (PA DS, Patient Archiving and Documentation System) user compliance can be improved. ''Bypassing'' mechanisms can be partly reversed (up to 43%) , more coded diagnoses are documented (by 51 %) and those diagnoses do cumented are more complete (increase by 57 %).