Abstract
[Objective] This study aimed to establish a standardized framework for electronic medical records in acupuncture and moxibustion by analyzing records, identifying key terms, and evaluating coding feasibility. [Subjects and Methods] A cross-sectional survey design was employed, collecting data from six organizations specializing in acupuncture and moxibustion to analyze documented items in records. Term Frequency-Inverse Document Frequency (TF-IDF) values were used to evaluate the characteristics of each organization's records, with higher values indicating key terms. Subjective data were coded according to the International Classification of Primary Care, Second Edition, while intervention methods were coded based on the International Classification of Health Interventions. [Results] Data from 92 facilities were collected, resulting in a total of 3,080 record items. The highest TF-IDF values were found in different categories across organizations: treatment content for The Japan society of Acupuncture and Moxibustion and the All Nippon Acupuncture & Moxibustion Massage Association, physical findings for the Japan College Association of Oriental Medicine, palpation for the Japan Society of Acupuncture Course in Universities and The Japan Acupuncture and Moxibustion Association, and femalerelated terms for The Japan Traditional Acupuncture and Moxibustion Society. Coding was generally feasible for subjective information; however, symptoms like "sensitivity to heat" and "sensitivity to cold" presented challenges, as these did not align with existing codes in the International Classification of Primary Care, Second Edition. Forintervention methods, coding was generally possible using the International Classification of Health Interventions. However, details specific to acupuncture, such as the number of needles used or the gauge of needles, were difficult to encode withinthe current framework. [Discussion] The Japan Acupuncture and Moxibustion Association and All Nippon Acupuncture & Moxibustion Massage Association emphasized treatment details, whereas the Japan College Association of Oriental Medicine prioritized a clinical education perspective. The Association of Acupuncture and Moxibustion Universities and The Japan Acupuncture and Moxibustion Association recorded a high frequency of palpation and medical history, whereas The Japan Traditional Acupuncture and Moxibustion Society emphasized detailed patient interviews. Although most subjective data could be coded, the extensive range of classifications necessitated careful selection. Although the International Classification of Health Interventions offers useful general categories, modifications would be necessary to fully represent acupuncture practices, where specific details about interventions are clinically significant. [Conclusion] Careful selection of items and coding methods for acupuncture and moxibustion records is essential to support both clinical usability and research applications.
