Clinical vocabularies and terminologies: impact on the future of health information management.

Abstract

As standardized clinical vocabularies and terminologies are being developed, Health Information Management (HIM) practitioners must increase their knowledge of nomenclature and coding systems beyond the traditional ICD-9-CM and CPT. The limited scope of these classifications prevents them from serving as the standard vocabulary for the computer-based patient record. The American Health Information Management Association (AHIMA) Coding Futures Task Force provided insights into the knowledge and skills that HIM professionals will need as clinical vocabularies and terminologies become more integrated into health care systems. Certain characteristics are important in a clinical vocabulary and several clinical vocabularies are in use today.