퇴원 요약 상병 코드 자동생성 지원시스템

Young-Hi Kang1), Hune Cho*1), Il-Kon Kim1), Yun-Sik Kwak1)

1)경북대학교 의과대학 의료정보학교실

Abstract : Abstract: Diagnosis is inevitable clinical information in the discharge summary. Final diagnosis is recorded in codified form in the medical records, which is determined by ICD-10 or KCD4. Diagnosis in textually described in the paper medical record is manually translated into ICD-10 codes to be used for insurance reimbursement. In this paper a semi-automated coding method has been developed to facilitate to generate ICD-10 codes for the diagnosis in the discharge summary. This new method is expected to improve efficient implementation of manual based ICD coding management in the medical record department in hospital.
keyword : Clinical information, medical records, ICD-10

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