Abstract
An ambulatory-care patient-tracking system has been implemented that records non-categorical problem descriptions in the outpatient problem list. The system does not restrict physicians to the use of predefined diagnostic categories. Instead, the system stores patient problems in a database as free-text records. Subsequent diagnostic categorization and coding is accomplished through prompted free-text input and appropriate reference databases. This system design allows an outpatient problem-list summary to reflect non-categorical health-status information in addition to coded medical diagnoses.
Full text
PDF
Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Banoub S. N. The need for new and short lists of classifications in health care. A proposed management classification for primary health care services: the 4-P classification. Med Inform (Lond) 1990 Oct-Dec;15(4):293–308. doi: 10.3109/14639239009025278. [DOI] [PubMed] [Google Scholar]
- Feinstein A. R. ICD, POR, and DRG. Unsolved scientific problems in the nosology of clinical medicine. Arch Intern Med. 1988 Oct;148(10):2269–2274. doi: 10.1001/archinte.148.10.2269. [DOI] [PubMed] [Google Scholar]
- Ingersoll S., Personnett J. D. A simplified approach to the ambulatory care diagnostic summary list. QRB Qual Rev Bull. 1990 Mar;16(3):127–129. doi: 10.1016/s0097-5990(16)30348-7. [DOI] [PubMed] [Google Scholar]
- Lane C. D., Walton J. D., Shortliffe E. H. Graphical access to medical expert systems: II. Design of an interface for physicians. Methods Inf Med. 1986 Jul;25(3):143–150. [PubMed] [Google Scholar]
- Maxwell D. M. Coding diagnoses with a microcomputer. MD Comput. 1990 Jul-Aug;7(4):262–263. [PubMed] [Google Scholar]
- Ramsay A., Peterson T., Earle D. Improving the accuracy of the computerized medical record. Top Health Rec Manage. 1989 Sep;10(1):29–35. [PubMed] [Google Scholar]
- Weed L. L. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593–600. doi: 10.1056/NEJM196803142781105. [DOI] [PubMed] [Google Scholar]