Towards a rule-based support system for the coding of health conditions in the patient summary

In the frame of federated and interoperable Electronic Health Records (EHRs), specific coding systems are mandatory for filling out healthcare documents such as the Patient Summary (PS). PS cannot be automatically generated from the patient’s EHR data, because of the sensitivity of its content. For this reason it needs to be validated by a General Practitioner (GP), who is the sole responsible of this document. The literature shows that the practice of coding is recognized as a difficult task for GPs and it often generates coding errors and misspecifications of clinical data. To overcome this issue, a support system based on standardized and formalized coding rules for the domain of application is proposed, to facilitate a more accurate coding process without breaking the law.