ICD-10 impact on ascertainment and accuracy of oral cleft cases as recorded by the Brazilian national live birth information system

2018 ◽  
Vol 176 (4) ◽  
pp. 907-914 ◽  
Author(s):  
Ricardo Lima do Nascimento ◽  
Eduardo E. Castilla ◽  
Maria da Graça Dutra ◽  
Iêda M. Orioli
Keyword(s):  
Information System ◽  
Live Birth ◽  
Oral Cleft ◽  
Icd 10 ◽  
Birth Information

scholarly journals PERANCANGAN SISTEM INFORMASI REKAM MEDIS ELEKTRONIK RAWAT JALAN BERBASIS WEB DI KLINIK GIGI BRIGHT SMILES BALI

2018 ◽  
Vol 4 (1) ◽  
Author(s):  
Dewa Made Andika Dwi Prawiradirjo ◽  
Bambang Hadi Kartiko ◽  
Gerson Feoh
Keyword(s):  
Information System ◽  
Life Cycle ◽  
Data Management ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Web Based ◽  
Patient Medical Record ◽  
Code Search ◽  
Development Life Cycle ◽  
Icd 10

ABSTRACT<br />The medical record officer at Bright Smiles Bali Clinic is still having difficulty in the process of<br />managing the data of outpatients because the clinic still using manual system that has not been<br />computerized. So it is necessary to design a web-based electronic medical record information system<br />that can help medical record officer in patient data management process. The method used in the<br />design of this system is the system development life cycle (SDLC) which consists of the planning,<br />analysis, design, implementation, and usage phases. The purpose and benefits of this information<br />system design is to produce a web based outpatient medical record information system at Bright<br />Smiles Bali Clinic.This information system facilitate medical record officer in carrying out patient<br />data management covering patient registration process, recording of patient medical record, doctors<br />data recording, code search on ICD 9 CM, code search on ICD 10. Besides, this information system<br />produces various reports as well as patient medical record information that management needs for<br />decision making.<br />Keywords: Information System, Electronic Medical Record, Outpatient, Web.<br />ABSTRAK<br />Petugas rekam medis di Klinik Gigi Bright Smiles Bali masih kesulitan dalam proses pengelolaan data<br />pasien rawat jalan karena masih menggunakan sistem manual yang belum terkomputerisasi. Maka<br />diperlukan sebuah sistem informasi rekam medis elektronik berbasis web yang dapat membantu<br />petugas rekam medis dalam proses pengelolaan data pasien tersebut. Metode perancangan sistem ini<br />menggunakan siklus hidup pengembangan sistem (Systems Development Life Cycle-SDLC) yang<br />terdiri dari tahap perencanaan, analisis, desain, implementasi, dan penggunaan. Sedangkan tujuan dan<br />manfaat dari perancangan sistem informasi ini yaitu menghasilkan sistem informasi rekam medis<br />elektronik rawat jalan berbasis web di Klinik Gigi Bright Smiles Bali. Dengan adanya sistem informasi<br />ini, dapat memudahkan petugas rekam medis dalam pengelolaan data pasien yang meliputi proses<br />pendaftaran pasien, pencatatan rekam medis pasien rawat jalan, pencatatan data dokter, pencarian kode<br />ICD 9 CM, pencarian kode ICD 10. Selain itu sistem informasi ini menghasilkan berbagai laporanlaporan<br />serta informasi rekam medis pasien yang dibutuhkan pihak manajemen untuk pengambilan<br />keputusan.<br />Kata Kunci : Sistem Informasi, Rekam Medis Elektronik, Rawat Jalan, Web.

scholarly journals Prevalence and Analysis of Inborn Birth Defects in A Tertiary Level Hospital in Bangladesh

2019 ◽  
Vol 3 (5) ◽  
Keyword(s):  
Risk Factors ◽  
Birth Weight ◽  
Low Birth Weight ◽  
Congenital Malformation ◽  
Live Birth ◽  
Birth Defects ◽  
Gestational Age ◽  
Still Birth ◽  
New Born ◽  
Icd 10

Objective: To assess the prevalence of congenital defects and to investigate the maternal and perinatal aspects in relation to the detailed ICD-10 coding of each individual case using The New Born Data base NBBD data collection system under Global surveillance in collaboration with Center for Disease Control CDC, Atlanta and All India Institute of Medical Science AIMS, New Delhi and Bangabandhu Sheikh Mujib Medical University BSMMU as the Focal point of investigation. Methods: All births and terminations of pregnancy beyond 24 weeks with structural and sonographically detectable birth defects from October,2014 to October, 2018 in the Department of Obstetrics and Gynaecology of Bangladesh Medical College and Hospital were carefully scrutinized and detailed information regarding the maternal and associated clinical risk factors were compiled using the NBBD (New Born Birth Defects) surveillance system. Among that period all births (Live birth and still birth) were counted to have a prevalence data of birth defects using the total number of births as the denominator and the number of birth defects as the numerator. Results: The prevalence of detectable birth defects among the 2002 total births (which includes 110 still births) was found to be 4.34% (87/2002 x 100). According to birth defect category using the ICD-10 coding system, 11 broad categories were found. Musculoskeletal deformities Q65-Q79 were the highest (25/87), followed by congenital malformation of the nervous system Q00-Q07(15/87) and congenital malformation of eye, ear, face and neck Q10-Q18(14/87). The birth defects were categorized as isolated, syndrome and sequence; among the 87 cases, 44 were isolated defects, 40 were syndromic / multiple birth defects and 3 were result of Potter sequence. Regarding maternal variables, maternal age<18 years was 23.4%, 18-25 years was 48.93% ,26-33 years was 23.4% and ≥ 34 years was 6.4%; father’s age < 35 yearswas 74.5% and ≥ 35 years 25.5%%, parental consanguinity was present in 4.3% of case. Analyzing the variables relating to labour conditions, majority of pregnancies were singletons 95.7% leaving only 4.3% of pregnancies being Twin pregnancies. Reviewing babies according to gestational age, 69 (73.4%%) of babies were less than 34 weeks and 26.6% remaining were equal to/more than 34 weeks of gestation reflecting a higher frequency of prematurity or pre-term delivery either induced or spontaneous onset. Regarding the mode of delivery, vaginal birth was conducted in approximately 74% of cases and C-Section was performed in remaining cases, the indication of C-section was guided by obstetric causes such as previous C-section and maternal desire for an elective abdominal delivery. Results of the foetal variables by sex distribution showed a significant male predominance (51/87) 51 male, 26 female and 10 ambiguous. Reviewing babies according to gestational age, 64 (73.4%%) of babies were less than 34 weeks and 26.6% remaining were more than 34 weeks of gestation reflecting a higher frequency of prematurity. The studied foetal variable as categorized by weight, as ≤1500gm (extreme low birth weight ELBW) was 23.4%, 1501-2499gm (Low birth weight LBW) was 50% and ≥2500g (Average birth weight) was 26.6 %. The studied foetal variable as categorized by percentage of babies that were born live birth was 87%, 17 % were stillbirth: a significant portion of those terminated late were found macerated. Data was also compiled regarding the following risk factors: Previous history of birth defects/ previous still birth/ previous spontaneous abortions/ terminations for birth defects which did not reveal significant differences. Conclusion: The study notified only the most visible defects in most cases. However, the study is part of an ongoing surveillance program which has incited much alertness among the participants regarding documentation. The prevalence records and the type of defects may help in the expansion of these programs for the development of future preventive strategies.

scholarly journals PERANCANGAN SISTEM INFORMASI REKAM MEDIS BERBASIS WEB (STUDI KASUS DI KLINIK BERSALIN SRIATI KOTA SUNGAI PENUH – JAMBI)

2016 ◽  
Vol 2 (2) ◽  
Author(s):  
Tiara Handayani ◽  
Gerson Feoh
Keyword(s):  
Information System ◽  
Life Cycle ◽  
Medical Record ◽  
Medical Records ◽  
Systems Development ◽  
Patient Data ◽  
Web Based ◽  
Development Life Cycle ◽  
Icd 10 ◽  
Maternity Clinic

<p>ABSTRACT<br />The records officer at Maternity Clinic Sriati Sungai Penuh - Jambi in its management and reporting of patient data are still using manual systems. It has caused a delay in the delivery of information and report on daily data patients. Thus, it needs a system of web-based medical record information that can assist officers in the medical record of the patient data management processing. This system design method uses development life cycle (Systems Development Life Cycle-SDLC) which consists of planning, analysis, design, implementation, and use. Meanwhile, the purpose and benefits of the design of this information system is to produce a system of web-based medical record information in Maternity Clinic Sriati River Sungai Penuh - Jambi. With this information system, it eases medical records clerk in the management of patient data whichh includes patient registration process, the recording of patient medical records, physician data recording, data recording space, the search code ICD 9 CM and ICD code search 10. In addition, this information system produces a variety of reports and patient medical record information that is required for management decision making.<br />Keywords: Information Systems, Medical Record, Maternity Clinic, Web.<br />ABSTRAK<br />Petugas rekam medis di Klinik Bersalin Sriati Kota Sungai Penuh - Jambi dalam pengelolaan dan pembuatan laporan data pasien masih menggunakan sistem manual. Hal ini menyebabkan terjadinya keterlambatan dalam penyampaian informasi dan pelaporan data harian pasien. Maka diperlukan sebuah sistem informasi rekam medis berbasis web yang dapat membantu petugas rekam medis dalam proses pengelolaan data pasien tersebut. Metode perancangan sistem ini menggunakan siklus hidup pengembangan sistem (Systems Development Life Cycle-SDLC) yang terdiri dari tahap perencanaan, analisis, desain, implementasi, dan penggunaan. Sedangkan tujuan dan manfaat dari perancangan sistem informasi ini yaitu menghasilkan sebuah sistem informasi rekam medis berbasis web di Klinik Bersalin Sriati Kota Sungai Penuh - Jambi. Dengan adanya sistem informasi ini, dapat memudahkan petugas rekam medis dalam pengelolaan data pasien yang meliputi proses pendaftaran pasien, pencatatan rekam medis pasien, pencatatan data dokter, pencatatan data ruang, pencarian kode ICD 9 CM, dan pencarian kode ICD 10. Selain itu sistem informasi ini menghasilkan berbagai laporan-laporan serta informasi rekam medis pasien yang dibutuhkan pihak manajemen untuk pengambilan keputusan.<br />Kata kunci: Sistem Informasi, Klinik Bersalin, ICD 9 CM, ICD 10</p>

Automatisierte Berechnung und Visualisierung von Komorbiditätsindizes für den Tumorboard-Entscheid

2020 ◽  
Vol 41 (08) ◽  
pp. 536-541
Author(s):  
Theresa Wald ◽  
Klemens Birnbaum ◽  
Susanne Wiegand ◽  
Andreas Dietz ◽  
Veit Zebralla ◽  
...  
Keyword(s):  
Information System ◽  
Record Linkage ◽  
Hospital Information System ◽  
Icd 10 ◽  
Kurative Therapie

Zusammenfassung Einleitung Komorbidität beeinflusst die für die kurative Therapie von Kopf-Hals-Karzinomen (HNC) verfügbaren Optionen. Das manuelle Zusammentragen der Nebenerkrankungen vor der Anmeldung im interdisziplinären Tumorboard (TB) ist zeitintensiv und oft unvollständig. Eine automatisierte Erfassung von nach ICD-10 kodierten Komorbiditätsdaten und deren Darstellung könnte die therapeutische Entscheidungsfindung im TB verbessern sowie bestehenden Informationsbedarf aufzeigen. Material und Methoden Die ICD-10-Codes unserer Patienten wurden aus 4 Datenbanken (hospital-information-system (HIS*-MED), der klinikinternen Tumordatenbank, OncoFlow® und OncoFunction®) extrahiert. Nach der Datensatzverknüpfung mittels der Python-Programmbibliotheken Pandas und Record Linkage wurden die ICD-10-Codes bezüglich des Charlson-Scores gewichtet und für die Implementierung in OncoFlow visualisiert. Die Kodierqualität wurde am Beispiel Diabetes an einer 1:1 gematchten Stichprobe von 240 Patienten überprüft. Ergebnisse 29 073 ICD-10-Codes von 2087 Patienten mit HNC wurden extrahiert. Die Anmeldung eines Patienten im TB triggert die sofortige automatische Erfassung und Visualisierung der Daten als Piktogramm in OncoFlow. Dies ermöglicht die schnelle Erfassung und Bewertung der Komorbidität sowie erforderlicher Diagnostik zur Komplettierung der Daten. Die klinikinterne Validationsstudie ergab eine Präzision der durch Datenimport verfügbaren Information zu Diabetes von 95,0 %. Diskussion Patienten mit HNC weisen häufig für die Therapieentscheidung relevante Nebenerkrankungen auf. Die automatisierte Erfassung der Komorbidität aus administrativen Daten und deren intuitive Darstellung ist ressourcen- und kostengünstig möglich. Voraussetzung ist eine präzise, vollständige Verschlüsselung der Krankheitsdiagnosen.

scholarly journals Factors associated with hospital admissions due to hypertension

2018 ◽  
Vol 16 (3) ◽  
Author(s):  
Rosimery Cruz de Oliveira Dantas ◽  
João Paulo Teixeira da Silva ◽  
Davidson Cruz de Oliveira Dantas ◽  
Ângelo Giuseppe Roncalli
Keyword(s):  
Primary Care ◽  
Information System ◽  
Linear Regression ◽  
Arterial Hypertension ◽  
Hospital Admissions ◽  
Descriptive Analysis ◽  
Secondary Data ◽  
Icd 10 ◽  
Essential Arterial Hypertension ◽  
Sensitive Conditions

ABSTRACT Objective: To study the temporality of hospital admissions due to arterial hypertension and its associated factors. Methods: An ecological study with secondary data on hospital admissions due to essential arterial hypertension – ICD 10, from the Hospital Information System, the Mortality Information System and and the Primary Care Information System, between 2010 and 2015. Descriptive analysis using means, proportions and linear regression. Results: We recorded 493,299 hospitalizations due to arterial hypertension from 2010 to 2015, with an average annual progressive cost decrease of −7.76% and −24.21%. Of the patients admitted, 59.2% were women, 60.2% were non-white and 54.7% were older than 60 years. The mean length of stay was 4.2 days, and the hospitalization cost was R$307.60. The multiple linear regression variables that remained significant were the percentage of admissions due to primary care-sensitive conditions, the per capita income and the City Human Development Index. Conclusion: Hospital admissions due to arterial hypertension have an impact on the percentage of admissions due to primary care- sensitive conditions. Intensifying primary care activities, raising-awareness among professionals to the importance of integrated care, and investing in social development are crucial to change the reality of hypertension in terms of its control and complications.

scholarly journals Effectiveness of the Live Births Information System in the Far-Western Brazilian Amazon

2015 ◽  
Vol 20 (4) ◽  
pp. 1245-1254 ◽  
Author(s):  
Jamille Gregório Dombrowski ◽  
Ricardo Ataíde ◽  
Paola Marchesini ◽  
Rodrigo Medeiros de Souza ◽  
Cláudio Romero Farias Marinho
Keyword(s):  
Information System ◽  
Live Birth ◽  
Information Quality ◽  
Health Indicators ◽  
Public Health Policies ◽  
Lack Of Information ◽  
Birth Characteristics ◽  
Data Source ◽  
Specific Health

The Live Birth Information System (SINASC) was implemented in 1990 for the purpose of providing information about the live-birth characteristics for the establishment of specific health indicators. This work evaluates the information quality of SINASC in relation to its data completeness and coverage for five municipalities from the State of Acre from 2005 to 2010. Lack of information (not filled out or stated as "unknown") was estimated for each variable. Coverage was estimated comparing the Civil Register office statistics in accordance with the mother's municipality of residence. An increase in incompleteness of the majority of variables was observed, and also a decrease in coverage between 2005 and 2010 in these municipalities. These findings do not tally with results from the majority of studies that use SINASC as a data source. The results of this work highlight the relevance of continuous capacity building and the incentive for accurate and complete data inclusion, as well as awareness of the importance of SINASC for public health policies.

ICD-10 Mortality Coding and the NEIS: A Comparative Study

2007 ◽  
Vol 36 (2) ◽  
pp. 11-23 ◽  
Author(s):  
Leanne Daking ◽  
Leonie Dodds
Keyword(s):  
Information System ◽  
Comparative Study ◽  
Cause Of Death ◽  
Australian Bureau ◽  
Mortality Data ◽  
Limited Access ◽  
Icd 10 ◽  
Australian Bureau Of Statistics

The collection and utilisation of mortality data are often hindered by limited access to contextual details of the circumstances surrounding fatal incidents. The National Coroners Information System (NCIS) can provide researchers with access to such information. The NCIS search capabilities have been enhanced by the inclusion of data supplied by the Australian Bureau of Statistics (ABS), specifically the ICD-10 Cause of Death codeset. A comparative study was conducted to identify consistencies and differences between ABS ICD-10 codes and those that could be generated by utilising the full NCIS record. Discrepancies between the two sets of codes were detected in over 50% of cases, which highlighted the importance of access to complete and timely documentation in the assignment of accurate and detailed cause of death codes.

scholarly journals Incompleteness and inaccuracies in Certificates of Live Birth in a city in Southern Brazil

2021 ◽  
Vol 24 (suppl 1) ◽  
Author(s):  
Daiane dos Santos ◽  
Leo Lynce Valle de Lacerda ◽  
Luciane Peter Grillo ◽  
Tatiana Mezadri
Keyword(s):  
Information System ◽  
Birth Weight ◽  
Live Birth ◽  
Maternal Age ◽  
Southern Brazil ◽  
Pregnancy And Childbirth ◽  
Using Data ◽  
Type Of Delivery

ABSTRACT: Objective: To evaluate inadequacies in Certificates of Live Birth in a city in Southern Brazil between 2011 and 2015. Methods: This is a retrospective quantitative study based on Certificates of Live Birth of mothers living in Itapema, Santa Catarina, issued from 2011 to 2015, using data from the Live Birth Information System. Results: Among 3,537 certificates, we found no mistakes in the variables newborn's sex, birth weight, maternal age, type of pregnancy, and type of delivery. Concerning incompleteness, the variable “cesarean section was performed before the start of labor” had a mean rate considered poor, while occupation was classified as good (above 6%), neighborhood as excellent (between 0.8 and 4.5%), and induction also as excellent (0.7 to 2.9%). Inaccuracies were greater in the ethnicity (up to 0.7%) and neighborhood (up to 1.3%) variables, both considered excellent. In the comparison between sections, the pregnancy and childbirth section was the most incomplete. Conclusion: Data completeness in Certificates of Live Birth was considered excellent for most variables, and the classification of inaccuracies was excellent for all variables, evidencing the quality of the information found in these certificates.

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