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Nomenclatore Per L'anatomia Patologica Italiana Arrigo Bondi

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Nomenclatore Per L'anatomia Patologica Italiana Arrigo Bondi NAP Nomenclatore per l’Anatomia Patologica Italiana Versione 1.9 Arrigo Bondi Bologna, 2016 NAP v. 1.9, pag 2 Arrigo Bondi * NAP - Nomenclatore per l’Anatomia Patologica Italiana Versione 1.9 * Componente Direttivo Nazionale SIAPEC-IAP Società Italiana di Anatomia Patologica e Citodiagnostica International Academy of Pathology, Italian Division NAP – Depositato presso S.I.A.E. Registrazione n. 2012001925 Distribuito da Palermo, 1 Marzo 2016 NAP v. 1.9, pag 3 Sommario Le novità della versione 1.9 ............................................................................................................... 4 Cosa è cambiato rispetto alla versione 1.8 ........................................................................................... 4 I Nomenclatori della Medicina. ........................................................................................................ 5 ICD, SNOMED ed altri sistemi per la codifica delle diagnosi. ........................................................... 5 Codifica medica ........................................................................................................................... 5 Storia della codifica in medicina .................................................................................................. 5 Lo SNOMED ............................................................................................................................... 6 Un Nomenclatore per l’Anatomia Patologica Italiana ................................................................. 6 Il NAP .................................................................................................................................................. 7 Strategia di realizzazione ..................................................................................................................... 7 Il codice NAP ............................................................................................................................... 7 Vantaggi del NAP ........................................................................................................................ 8 Limiti del NAP ............................................................................................................................. 8 NAP ed altri nomenclatori ........................................................................................................... 8 ICD 9 e DRG................................................................................................................................ 8 ICD-O........................................................................................................................................... 9 SNOMED CT ............................................................................................................................... 9 LOINC ......................................................................................................................................... 9 Versioni di NAP ........................................................................................................................... 9 Lista dei termini inclusi nel NAP .................................................................................................... 10 Elenco in ordine di codice ................................................................................................................. 10 T - Anatomia .............................................................................................................................. 10 M - Morfologia........................................................................................................................... 10 P - Procedure .............................................................................................................................. 10 D - Malattie ................................................................................................................................ 10 G - Connettori / Modificatori ..................................................................................................... 10 L - Organismi Viventi ................................................................................................................ 10 A - Agenti fisici, Attività e Forze .............................................................................................. 10 C - Composti chimici ................................................................................................................. 10 F - Funzioni ................................................................................................................................ 11 J - Occupazioni........................................................................................................................... 11 Schema della costruzione del codice NAP ................................................................................ 12 Acronimi .................................................................................................................................... 14 Bibliografia. ...................................................................................................................................... 14 NAP Nomenclatore per l'Anatomia Patologica Italiana ver. 1.9 ................................................. 17 Stampa completa del nomenclatore, compreso nella tabella del file Access ................. 17 – 613 NAP v. 1.9, pag 4 NAP: Le novità della versione 1.9 Cosa è cambiato rispetto alla versione 1.8 1° Marzo 2016 I. La novità più importante è la modalità di distribuzione: ora è possibile scaricare il volume NAP, la tabella completa in formato Access ed i files accessori dal sito di SIAPEC Servizi (http://www.siapecservizi.it/). È necessario ottenere le credenziali di accesso da SIAPEC Servizi. II. Nella versione 1.9 sono inclusi 26306 termini + 2 record di configurazione: il primo è il titolo della Tabella (NAP, appunto) e l’ultimo, che contiene un numero di identificazione della versione (cod. Z-51055656) III. I 26306 termini sono così suddivisi nei capitoli (o assi, vedi Tabella 1 a pag. 8): P- 1011, G- 3259, L- 519, T- 6472, R- 1766, A- 299, M- 7770, F- 864, altri (S,J,X,N e Z) 30. D- 3642, C- 674, IV. Rispetto alla versione precedente sono stati aggiunti 716 termini o titoli nuovi, in 22 record è stato modificato il campo COD (in 5 anche corretto il testo) per riparare errori o aggiustare sinonimi, in 132 record è stato corretto il campo TXT, in prevalenza per eliminare termini accentati che in alcuni sistemi non vengono stampati correttamente. V. Sono inclusi 25327 termini generali (Gruppo A) e 981 titoli di capitoli (Gruppo S). VI. Il tracciato record del nomenclatore NAP è stato ampliato: oltre ai tre campi essenziali, già presenti nelle versioni precedenti, ID = identificatore univoco del record, comune a tutte le versioni COD = codice NAP TXT = testo di decodifica sono stati aggiunti altri tre record opzionali per facilitare la gestione del nomenclatore Gruppo = indica se si tratta di un termine per codifica (A) o di un titolo di capitolo (S) Super = puntatore del “COD padre” per costruire raggruppamenti logici entro il nomenclatore (indice logico) ICD = campo sperimentale, solo parzialmente compilato (sarà completato nelle release successive), che contiene un link col nomenclatore ICD-O (assi M e T), per facilitare l’uso di NAP sincrono ad ICD. VII. I nuovi campi forniscono indicazioni importanti per caricare NAP nei sistemi gestionali con finalità di codifica diagnostica: anche se è sufficiente selezionare solo i campi essenziali (i primi tre) è fortemente consigliabile filtrare i record con Gruppo=“A” così da non includere i titoli dei capitoli nei gestionali di laboratorio o negli applicativi per codifica diagnostica. VIII. I titoli dei capitoli hanno codice lungo meno di 10 digit, hanno il testo scritto in MAIUSCOLO, servono per identificare gli insiemi logici con cui organizzare il nomenclatore, dove il campo SUPER indica il COD del “raggruppamento padre” per ogni termine o capitolo. Se caricati in sistemi di codifica e resi disponibili ai compilatori, si possono realizzare codifiche “su capitoli” ed altre “su termini di base”, con lo stesso significato ma con codice diverso. IX. I titoli (record di Gruppo “S”) ed i puntatori del campo Super rappresentano il presupposto per costruire cataloghi di consultazione con priorità logiche e per facilitare la codifica diagnostica. Il software per costruire un catalogo organizzato in raggruppamenti logici NON è incluso in NAP ma deve essere sviluppato da terze parti o entro i gestionali locali. NAP v. 1.9, pag 5 I Nomenclatori della Medicina. ICD, SNOMED ed altri sistemi per la codifica delle diagnosi. Le parole usate nella formulazione delle diagnosi mediche, quando non sono sinistramente note (infarto, tumore, degenerazione...), rientrano in un elaborato vocabolario tecnico ricco di sinonimi, acronimi, abbreviazioni, vocaboli equivalenti, eponimi, termini composti. Questa variegata e complicata terminologia è sorprendentemente efficace nella comunicazione diagnostica fra medici ma è molto meno adeguata quando si tratta di raggruppare casi simili, analizzare la frequenza o valutare la diffusione delle malattie nella popolazione o in un determinato territorio. Da molto tempo epidemiologi, statistici ed anche matematici hanno elaborato sistemi per trasformare il complicato linguaggio della medicina in codici simbolici, spesso in formato numerico, per ordinare, sommare, suddividere o valutare con algoritmi standardizzati
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