Indexing the patient recordfile: a 15-year experience in a French hospital

摘要

While the electronic patient record is promoted, important issues remain on organization of document storage and on browsing facilitation between large amounts of documents. As bookmarks for large encyclopedias, indexing codes appears to be the mean for focalizing entries in the data. As a consequence, the access to information will necessitate powering indexing and traceability methods. In the other hand, most of the western countries have developed economical models for hospital funding, based on standardized description of cares during hospitalization according to predefined nomenclatures and classifications. However, indexing the discharge abstract is fastidious and time-consuming, especially for physicians who are, in France, in charge of this task. The Activity Based Payment policy offers real incentives for improving medical indexing. Based on our experience in an hospital medical information department, we report the quality assessment of medical indexing and we discuss some ways to ease the fastidious coding task and to improve the quality of indexation for optimizing the fund allocation and, as a consequence, for organizing and browsing the electronic patient record.