Validation of chief complaints, medical history, medications, and physician diagnoses structured with an integrated emergency department information system in Japan: the Next Stage ER system.

ABSTRACT:

Aim

Emergency department information systems (EDIS) facilitate free-text data use for clinical research; however, no study has validated whether the Next Stage ER system (NSER), an EDIS used in Japan, accurately translates electronic medical records (EMRs) into structured data.

Methods

This is a retrospective cohort study using data from the emergency department (ED) of a tertiary care hospital from 2018 to 2019. We used EMRs of 500 random samples from 27,000 ED visits during the study period. Through the NSER system, chief complaints were translated into 231 chief complaint categories based on the Japan Triage and Acuity Scale. Medical history and physician's diagnoses were encoded using the International Classification of Diseases, 10th Revision; medications were encoded a

SUBMITTER: Goto T 

PROVIDER: S-EPMC7453131 | biostudies-literature | 2020 Jan-Dec

REPOSITORIES: biostudies-literature