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Related Concept Videos

Discharge Summary Forms01:31

Discharge Summary Forms

The discharge summary is crucial as it enables a smooth transition from a healthcare facility to a patient's home or another care setting. This critical document facilitates seamless continuity of care, ensuring patients receive the necessary support and attention.
Here's a detailed look at the key components and guidelines for preparing a discharge summary:
Data Reporting and Recording01:24

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
Flow Sheet01:17

Flow Sheet

Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
Pharmacovigilance01:19

Pharmacovigilance

Post-marketing surveillance is a critical component of pharmaceutical regulation, often uncovering unanticipated adverse drug reactions (ADRs) once a drug is widely used over an extended period.
This process, termed pharmacovigilance, aims to detect, evaluate, and minimize harmful effects related to medication use. The data collection for pharmacovigilance depends on spontaneous reporting systems, where healthcare professionals or patients voluntarily report suspected ADRs.
In some cases, there...

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Related Experiment Video

Updated: May 29, 2026

Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index
06:55

Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index

Published on: January 8, 2020

Checking coding completeness by mining discharge summaries.

Stefan Schulz1, Thorsten Seddig, Susanne Hanser

  • 1University Medical Center Freiburg, Germany. xstefan.schulz@medunigraz.at

Studies in Health Technology and Informatics
|September 7, 2011
PubMed
Summary
This summary is machine-generated.

A new text classification system identifies non-coded secondary diseases in hospital records by scanning drug names. This method helps uncover missing diagnoses like diabetes mellitus and asthma/COPD, improving data accuracy.

Related Experiment Videos

Last Updated: May 29, 2026

Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index
06:55

Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index

Published on: January 8, 2020

Area of Science:

  • Medical Informatics
  • Health Information Systems
  • Clinical Coding

Background:

  • Incomplete coding of secondary diseases is a significant issue in hospital information systems.
  • Accurate coding is crucial for patient care, research, and healthcare management.

Purpose of the Study:

  • To develop and evaluate a text classification system for detecting non-coded secondary diseases.
  • To identify treatment episodes lacking appropriate ICD-10 codes for specific conditions.

Main Methods:

  • Developed a text classification system scanning discharge summaries for drug names.
  • Utilized a drug knowledge base linking drug names to ICD-10 codes.
  • Identified discrepancies between drug mentions and existing ICD-10 codes in patient records.

Main Results:

  • The system detected non-coded cases for diabetes mellitus, Parkinson's disease, and asthma/COPD.
  • Precision varied by condition: 79% for diabetes, 14% for Parkinson's, and 45% for asthma/COPD.
  • Estimated recall values were 43% for diabetes, 70% for Parkinson's, and 36% for asthma/COPD.

Conclusions:

  • The system effectively identifies potential non-coded secondary diseases, highlighting significant undercoding for diabetes and asthma/COPD.
  • An estimated 716 non-coded diabetes cases and 420 non-coded asthma/COPD cases were identified among 34,865 treatment episodes.
  • This approach can improve the completeness and accuracy of clinical coding in hospital information systems.