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Health & Coding Terminological Systems Health & Coding Terminological Systems Hamideh Sabbaghi, MS Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran Definition of Code Code is considered as word, letter, or number which has been used as passwords instead of words or phrases. Coding System 1. Classification system 2. Nomenclature system Classification System A well-known system of corrections for naming different stages of the disease. Nomenclature System A medical list of a specific system of preferred terms for naming disease. WHO- FIC • Main/reference classification • Related classifications to the main/ reference classification • Driven classification from the main/ reference classification Main/reference classification • ICD- 10 (1990, WHA) • ICD- 11 (2007, WHO) • http://who.int/classifications/apps/icd/icd10online/ ICD with a commonest usage can be used for: • Identification of health trend, mortality and morbidity statistics. • Clinical and health research purposes. Main/reference classification • ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) • ICF (International Classification of Function, Disability and Health) • ICHI (International Classification of Health Intervention) Related classifications to the main/ reference classification • ATC/DDD (The Anatomical Therapeutic chemical classification system with Defined Daily Doses) • ATCvet (The Anatomical Therapeutic Chemical Classification System for veterinary medicinal products) • ICECI (International Classification of External Causes of Injury) • ICPC (International Classification of Primary Care) • Assistive products for persons with disability- Classification and terminology (ISO9999) • ICNP (International Classification for Nursing Practice) Driven classification from the main/ reference classification • ICD- DA (International Classification of Diseases to Dentistry and Stomatology) • ICD- 10- CDDG (ICD. 10- Clinical Descriptions & Diagnostic Guides) • ICD-NA (International Classification of Disease to Neurology) • ICD- O (International Classification of Disease For Oncology) • ICD-R&O (International Classification of Disease to Rheumatology and Orthopedics) • ICF-CY (International Classification of Disability in Children and Youth) • ICID (International Coding Index for Dermatology) • NOC (The Nursing Outcomes Classification) • DSM (Diagnostic Statistical Neonatal of Disorder) • ICSD (International Classification of Sleep Disorders) • NCECI (NOMESCO Classification of External Causes of Injuries) Nomenclature Systems • SNAI (Standard Nomenclature of Athletic Injuries) • INO (International Nomenclature of Ophthalmology) • MOTNAC (Manual of Tumor Nomenclature & coding) • CPT (Current Medical Procedures Terminology) • CMIT (Current Medical Information and Terminology) • SNOMED (Systematized Nomenclature of Medicine) • SNOMED- CT (Systematized Nomenclature of Medicine- Clinical Terms) • SNDO (Standard Nomenclature of Disease and Operation) • SNOP (Systematized Nomenclature of Pathology) • SNOVDO (Standard Nomenclature of Veterinary Diseases & Operations) • SNOVET (Systematized Nomenclature in Veterinary Medicine) • SNOAPAD (Standardized Nomenclature of Animal Parasitic Diseases) • SNDVO (Standard Nomenclature of Veterinary Disease and Operation) • SNO- DERM (Systematized Nomenclature of Dermatology) • Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels Nomenclature Systems • CMIT (Current Medical Information and Terminology) • GMDN (The Global Medical Device Nomenclature) • IND (International Nomenclature of Disease) • LOINC (Logical Observation Identifiers Names and Codes) • Med- DRA (Medical Dictionary) • UMDNS (Universal Medical Device Nomenclature System) • WHO- ART (The WHO Adverse Reaction Terminology) LOINC Nomenclature System • Clinical care management • This system is a universal standard for the identification of laboratory observations. • Nursing diagnosis, nursing interventions, classification of results and patient care data are identified addition to the laboratory observations. Objectives: • To facilitate the exchange and sharing of results such as blood hemoglobin, serum potassium and vital signs for clinical care, outcome management and research. LOINC Nomenclature System Laboratory Part • Standard Test Codes and Names • Medications and cell counts for blood and cerebrospinal fluid smears • Microbiology includes Parasitology, Virology, Serology, Hematology, Chemistry and Toxicology Clinical Part • Vital Signs • Electrocardiography • Pulmonary Ventilation Management • Cardiac echo • Urological Imaging • Obstetrical Ultrasound • Hemodynamic • Measures for gastric and duodenal examination • Other clinical observations LOINC Nomenclature System Advantages • Improving communications in integrated health delivery networks. • Support for error reduction through significant improvement in quality of care. • Support for integrated health electronic records. • Support the transmission of case reports of controlled or epidemic diseases. • Improved transfer of payment information for provided services. • Improvement of integrated health electronic records. It can be accessible freely via the URL address of http://www.regenstrief.org/loinc/. Med- DRA • It is a medical dictionary. • Using this system, the drug quality agencies are working to improve the quality of the drugs produced. Objectives • This system acts as a single language in the process of generating, transmitting and retrieving data about pharmaceuticals worldwide. • This system improves the efficiency and effectiveness of pharmaceutical product regulatory processes. RxNorm • It is a standard for naming clinical drugs and drug delivery devices. Objectives It allows different systems to be able to effectively share data. Med- DRA Advantages Enhancement of the effectiveness and efficiency of the regulatory processes for pharmaceutical and medical products. SNOMED This system is the latest and most comprehensive list of contents in the field of health. This system is hierarchical and multi- directions. The third edition of SNOMED is developed based on the 6 following fields: • Topography • Morphology • Etiology • Function • Disease • Medical proceedings SNOMED This terminological system has three characteristics: • Systematic structure • Multi- directions • Controlled vocabulary Other subdivisions of SNOMED are: • SNOMED- RT (SNOMED- Reference Terminology) • SNOMED- CT (SNOMED- Clinical Terms) SNOMED- RT • This system is mostly used to extract statistical information. • This system was developed to refer to alternative terms to one specific term. Objective • Data analysis • Cost effective research • Providing the knowledge base application instructions • Comparing the health care plans SNOMED- CT • SNOMED-CT has been known as a beneficial terminological system for standardization of complex medical concepts. • This system is used to encode all terms used to describe the disease condition. Objectives • This system is useful for facilitating communication and interoperability in the electronic exchange of health data. Thanks for Your Attention Email: [email protected].
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