Improving the quality of the coding of primary diagnosis in standardized discharge summaries

Health Care Manag Sci. 2008 Jun;11(2):147-51. doi: 10.1007/s10729-008-9060-0.

Abstract

We propose to design and test an information-processing model to participate in appraising the quality and the consistency of the coding, for billing, of Standardized Discharge Summaries (SDSs). We designed a model using both symbolic knowledge extracted from the NLM's UMLS and statistical knowledge. The aim is to retrieve from the ICD-10 terms recorded in a SDS the Principal Diagnosis (PD) at the time of coding. In 90% of cases the PD was retrieved 1st or 2nd in SDS including three ICD-10 codes or more. This model could contribute as part of an automated quality control process in a hospital information system by checking consistency in coded SDSs and improve the income of the hospital.

MeSH terms

  • Continuity of Patient Care / organization & administration
  • Hospital Administration
  • Humans
  • Information Systems / organization & administration
  • International Classification of Diseases*
  • Medical Records Systems, Computerized / organization & administration*
  • Patient Discharge*
  • Quality of Health Care / organization & administration*
  • Reproducibility of Results
  • Terminology as Topic
  • Vocabulary, Controlled