Journal of Health and Biomedical Informatics

Introduction: The Importance of disease classification for facilitating medical research is clear. The Medical diagnosis classification is usually done through International Classification of Disease (ICD) system. Sometimes, diagnostic terms in medical records require to be replaced by equivalent term according to international classification of disease system. In order to optimize the patient’ medical records, using information technology, especially designing and developing application in classification of local medical diagnosis are recommended. This research aimed to identify local cardiovascular diagnoses and develop an application for classification and coding them.

Method: This research is an applied study, conducted on 500 medical records in Mashhad Imam Reza and Ghaem hospitals. After that, the concept mapping developed between diagnostic terms and the ICD terms. Data were collected through observation, interview, and checklist, and then the application was developed for coding diagnoses. Furthermore, the coding agreement coefficient related to first and second final diagnoses recorded in medical records was calculated among three raters via interclass correlation coefficient (ICC).

Results: In this research, 1081 codes were investigated and 676 diagnoses of them were recorded in the record summary form. The number of the local diagnoses and abbreviations with their codes were 147 cases. The coding agreement rate among raters was 70% and 88% in the first and second final diagnosis, respectively.

Conclusion: Due to the excellent agreement between raters about the local cardiovascular terms performed through the coding application, it can be concluded that the designed application has high reliability in coding and can be used for classification of diagnoses in different hospital departments.