Direct physician entry of injury information and automated coding via a graphical user interface.

摘要

Injury data in the paper medical record are often inaccurate or lack adequate specificity to evaluate trauma patient care. To improve the quality of recorded injury data, we are testing a graphical, anatomic-based interface for quick collection of detailed injury information directly from the trauma physician. Navigation and data collection throughout the interface are facilitated by anatomic illustrations, menus, lists, and "dialog boxes". Using a "point and click" method, the user selects a specific anatomic structure (i.e., the spleen) from drawings. Detailed injury information, specific to the selected structure, is then collected from the user in an "intelligent" modal dialog box. The software uses SNOMED III nomenclature to create and store ICD, AIS, and trauma registry codes for each injury. Users can review and print abbreviated and detailed injury information for each patient. This demonstration will walk viewers through the injury collection and review process for injuries to the abdomen. We plan to evaluate the interface for accuracy, speed, user satisfaction and resources expended by comparing it with current methods of data collection and injury coding at our level I trauma facility.