An overview of coding and its relationship to standardized clinical terminology.

A H Peden
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引用次数: 0

Abstract

Coding systems and standardized clinical terminologies are interrelated. Coding schemes can be developed for classification systems, nomenclatures, and clinical terminologies. The coding systems most commonly used in the United States lose clinical detail and cannot meet the demands of the clinical information systems needed to support the computer-based patient record, outcomes studies, or risk-adjusted comparative research. Systems using computerized encoding and structured as terminologies offer more promise of providing the needed clinical detail. Companion systems can be developed to automatically place standardized clinical terms into less granular classification systems, such as ICD-9-CM, to maintain international compatibility and to continue federal programs based on such classifications.

概述编码及其与标准化临床术语的关系。
编码系统和标准化临床术语是相互关联的。可以为分类系统、命名法和临床术语开发编码方案。在美国最常用的编码系统丢失了临床细节,不能满足临床信息系统的需求,这些系统需要支持基于计算机的患者记录、结果研究或风险调整比较研究。使用计算机编码和结构化术语的系统更有希望提供所需的临床细节。可以开发配套系统,自动将标准化的临床术语放入较小粒度的分类系统中,如ICD-9-CM,以保持国际兼容性并继续基于此类分类的联邦计划。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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