The Development and Evaluation of a New Coding System for Medical Records

Purpose: The present study aims to develop a simple, reliable and easy tool enabling clinicians to codify the major part of individualized medical details (patient history and findings of physical examination) quickly and easily in routine medical practice, by entering data to a purpose-built software application, using structure data elements and detailed medical illustrations. Materials and Methods: We studied medical records of 9,320 patients and we extracted individualized medical details. We recorded the majority of symptoms and the majority of findings of physical examination into the system, which was named IMPACT (R) (Intelligent Medical Patient Record and Coding Tool). Subsequently the system was evaluated by clinicians, based on the examination of 1206 patients. Results: The evaluation results showed that IMPACT (R) is an efficient tool, easy to use even under time-pressing conditions. Conclusion: IMPACT (R) seems to be a promising tool for illustration-guided, structured data entry of medical narrative, in electronic patient records.