Improving the quality of the coding of primary diagnosis in standardized discharge summaries
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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.
KeywordsDischarge summary Medical record Hospital Quality improvement
We wish to thank Dr Christian Trapé who helped us perform the mapping between CCAM and ICD-10. Mrs Marthe-Aline Jutand and Dr Roch Giorgi for their well-informed advice on statistics. Dr Philip Robinson for help with manuscript preparation. The US. NLM which kindly provided the authors with the UMLS knowledge sources.
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