MEDCIN

Several Electronic Health Record (EHR) systems embed MEDCIN, which allows them to produce structured and numerically codified patient charts.

MEDCIN was initially developed by Peter S. Goltra, founder of Medicomp Systems “as an intelligent clinical database for documentation at the time of care.

Since 1978, the MEDCIN database engine has been continuously refined and expanded to include concepts from clinical histories, test, physical examination, therapies and diagnoses to enable coding of complete patient encounters with the collaboration of physicians and teaching institutions such as Cornell, Harvard, and Johns Hopkins.

[7][6] MEDCIN has been designed to work as an interface terminology[8] to include components to make EHRs more usable when it is used in conjunction with proprietary physician and nursing documentation tools.

[6] In August 2012, Medicomp Systems released an updated version of the software embedded with ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) mappings and functionality to comply with the transition from ICD-9-CM to ICD-10-CM as mandated by the US Department of Health and Human Services.

[13] The ICD-10 is published by the World Health Organization (WHO) to enable the systematic collection of morbidity and mortality data from different countries for statistical analysis.

[16] The CCC is directly linked in the MEDCIN nursing POC to medical terminology with the purpose of creating patient plan of care by extracting a pool of documentation from the EHR history.

Figure 1: AHLTA and MEDCIN terminology systems
Figure 2: MEDCIN plan of care with nursing diagnoses