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- W2884704568 abstract "The National Institute of Rehabilitation in Mexico has an electronic clinical record system in which health conditions are classified with ICD-10, in 2013 the functioning/disability registry is started according to Mexican regulations, where it is indicated that for the generation of statistics on the level of health and disability must meet the guidelines established by the WHO in the ICF in the overall functioning of people. The objective of this work is to make known the implementation of the registry of the diagnosis of functioning/disability (DFD) in an electronic clinical record (ECR). The DFD is recorded in the following notes of the ECR: initial note of external consultation, note of admission and hospital discharge. Characteristics of DFD: 1) Diagnosis of the four components. 2) Possibility of a wide range of n number of codes for each component. 3) Inclusion of the ICF catalog up to a second level. 4) Text writing is predictive. 5) Use of the raters from 0 to 4. 6) Mandatory use, without filling this section cannot record the medical note. Different analyzes have been carried out with different objectives: the functioning of the people served according to their health condition, their functioning during the time of their treatment, quality in the registry of functioning by the health person, among others. The main conclusions are: a) Continuation in the training of the ICF among the health personnel, since it is observed that some registered codes are not “congruent” with the health condition, as well as codes with terminations 8 and 9 (“other specified” and “unspecified”) That indicate the quality of health information. b) Development of the methodology to assess and qualify disability, since the registration does not conclude the degree of disability of the person served." @default.
- W2884704568 created "2018-08-03" @default.
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- W2884704568 date "2018-07-01" @default.
- W2884704568 modified "2023-09-30" @default.
- W2884704568 title "Registry of the functioning of patients in the electronic clinical record at the national institute of rehabilitation of Mexico" @default.
- W2884704568 doi "https://doi.org/10.1016/j.rehab.2018.05.1275" @default.
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