What are nomenclatures? describe clinical terminologies, classifications, and code systems.
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Ch. 5: Clinical Terminologies, Classifications, and Code SystemsI.History and Importance of Clinical Terminologies, Classifications, and Code Systems-HIMprofessionals play a crucial role in coding clinical data. Coding is the process of assigningnumeric or alphanumeric representations to clinical documentation. With the adoption ofEHR, the nomenclatures used to identify clinical data have increased in number and scope.Nomenclatures consist of a system of terms that follows pre-established namingconventions. A clinical terminology is a set of terms representing the system of concepts forthe medical field. Classifications are also a system where regulated entities are organizedtogether. An accumulation of numeric or alphanumeric representations or codes forexchanging or storing information is a coded system. Clinical terminologies, classifications,and code systems exist to name and arrange medical content so it can be used for patientcare, measuring patient outcomes, research, and administrative activities such asreimbursement. If data granularity, or the detail is the goal, then clinical terminologies arethe best options.A.Clinical Terminologies- Clinical terminologies form the basis of coded data and providethe data structure required for semantic interoperability and health informationexchange. Semantic interoperability is the mutual understanding of the meaning of dataexchanged between information systems. Clinical terminologies may also be referenceterminologies. A reference terminology in the health information technology (HIT)domain is a set of concepts and relationships that provide a mutual understanding forclinical decision support and for exchanging data with meaning about the healthcarecourse.B.SNOMED CT- The International Health Terminology Standards Development Organization(IHTSDO) defines SNOMED CT as a “comprehensive clinical terminology that providesclinical content and expressivity for clinical documentation and reporting”. According toIHTSDO, SNOMED CT is the most comprehensive, multilingual clinical terminology in theworld. There is no book of SNOMED CT codes and no coding professional assigns aSNOMED CT identifier. The terminology instead is implemented in software applicationswhere healthcare providers record clinical information using identifiers that refer toconcepts that are formally defined as a part of the terminology during the process ofcare. By, selecting the clinical term, the identifier is captured and thereby provides theprimary source of information about the patient.SNOMED CT Purpose and Use- SNOMED CT’s overall purpose is to standardizeclinical phrases, making it easier to produce accurate electronic healthinformation. Semantic interoperability is also possible. With the consistent,reliable], and comprehensive capture of clinical phrases with SNOMED CT itsuses and benefits are many. Show
Codes, classifications, terminologies and nomenclatures: definition, development and application in practiceSimon de Lusignan. Inform Prim Care. 2005. Free article AbstractThe Primary Care Informatics Working Group of EFMI is working to help develop the core theory of primary care informatics (PCI). Codes, classifications, terminologies and nomenclatures form an important part of the science of PCI, as they allow clinical information to be readily stored and processed in information systems. This article provides definitions and a history of the International Classification for Primary Care (ICPC), and of the Read code and the Systematized Nomenclature for Medicine (SNOMED). The Working Group wishes to encourage shared definitions and an understanding of the practical application of structured data to improve quality in clinical practice. Similar articles
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What are nomenclatures describe clinical terminologies?Nomenclature: A system of names used in a particular discipline, as in medicine and surgery, anatomy and biochemistry, etc. A standard system of nomenclature presupposes the existence of an organized classification of the entities within that field.
What are clinical terminologies classifications and code systems?Clinical terminologies, classifications, and code systems exist to name and arrange medical content so it can be used for patient care, measuring patient outcomes, research, and administrative activities. Their purpose in eCQM is exactly that and *to express healthcare performance data.
What are nomenclatures in coding?Nomenclature – a coding system using names (terminology), such as SNOMED that includes multiple levels of granularity. It provides a common language that enables a consistent way of indexing, storing, retrieving and aggregating clinical data across specialties and sites of care.
What is clinical terminology system?Clinical terminology systems are used to code the entire healthcare domain, from procedure to diagnosis and beyond. They function as a common reference system that uses compositional grammar concepts (conversation words) that can be coded and queried.
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