Semi-Automatical Encoding of Medical Diagnosis by Non-Professionals

A general model to codify medical diagnoses in a semi-automated simple and practical way is introduced. It uses a modularized conception which makes it flexible and extendable. This automation leads to an improvement in quality of the stored medical data by decreasing consistency errors between text and code. The model offers a simple way to achieve such an assignment by employing a qualified thesaurus which includes different kinds of variations (attributes, synonyms and abbreviations). The system uses a fixed logic and allows quick and precise data acquisition and processing which makes it transparent to non-expert users. It was applied to the discharge diagnoses at the MHH, according to the ‘Bundespflegesatzverordnung’ (BPf1V), and was inserted in the transferring and discharge functions of the patient admission system of the Medical System Hannover (MSH-Test). First results of this stage are presented.