Computerized pre-anesthetic evaluation results in additional abstracted comorbidity diagnoses.

Journal of clinical monitoring Pub Date : 1997-01-01 DOI:10.1023/a:1007320404788

G L Gibby, D A Paulus, D J Sirota, R W Treloar, K I Jackson, J S Gravenstein, J J van der Aa

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引用次数: 11

Abstract

Objective: To study the impact of information from a physician-entry computerized preanesthetic evaluation system on the coding of International Classification of Diseases (ICD-9-CM) diagnoses and on hospital reimbursement due to alterations in diagnosis-related group (DRG) codes.

Methods: Nonrandomized, unblinded trial conducted at a 570-bed university tertiary care hospital. First without and then with reference to information contained on computer-based preanesthetic evaluation reports, medical charts were coded by the study institution's usual professional codes for ICD-9-CM discharge diagnoses and DRG assignment.

Results: For 22 of 180 charts studied (12%, 95% confidence limits 7.4% to 16.7%), at least one ICD-9-CM diagnosis was added. Three of 84 DRG-based reimbursements were altered, increasing hospital reimbursement by 1.5%.

Conclusions: Supplemental information from a physician-entered, problem-oriented, computerized preanesthetic evaluation system improved discovery of diagnoses in the population studied.

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计算机化的麻醉前评估结果是附加的抽象的合并症诊断。

目的:研究由医生输入的计算机化麻醉前评价系统信息对国际疾病分类(ICD-9-CM)诊断编码的影响，以及对诊断相关组(DRG)编码变更引起的医院报销的影响。方法:在一所拥有570个床位的大学三级医院进行非随机、非盲法试验。首先没有，然后参考基于计算机的麻醉前评估报告中包含的信息，医疗图表由研究机构通常的ICD-9-CM出院诊断和DRG分配的专业代码编码。结果:在研究的180张图表中，有22张(12%，95%置信限7.4%至16.7%)至少添加了一个ICD-9-CM诊断。84项基于drg的报销中有3项发生了变化，使医院报销增加了1.5%。结论:来自医生输入的、问题导向的、计算机化的麻醉前评估系统的补充信息改善了所研究人群的诊断发现。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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Journal of clinical monitoring

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Thanks to reviewers Pulse oximetry. Abstracts of scientific papers third international symposium on computing in anesthesia Abstracts of scientific papers computers in anesthesia VI Monitoring in Anesthesia, Second Edition