Medical classification - Wikipedia, the free encyclopedia. Medical classification, or medical coding, is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers. The diagnoses and procedures are usually taken from a variety of sources within the health care record, such as the transcription of the physician's notes, laboratory results, radiologic results, and other sources. Diagnosis codes track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot.
Online Manual Medical Records Law in. This policy establishes principles and requirements for all medical records and. Organization of Medical Records. Electronic Health Records at http. Medical classification, or medical coding. The World Health Organization. Diagnostic and Statistical Manual of Mental Disorders. What are electronic medical records. Wesley Ratliff and Premier Healthcare Use Health IT to Build an Accountable Care Organization; Health Information Exchange. Procedure codes track interventions performed. These diagnosis and procedure codes are used by health care providers, government health programs, private health insurance companies, workers' compensation carriers, software developers, and others for a variety of applications in medicine, public health and medical informatics, including: There are country specific standards and international classification systems. Classification types. The number of categories is limited so that the classification does not become too big. An example of this is used by the International Statistical Classification of Diseases and Related Health Problems (known as ICD). ICD groups diseases of the circulatory system into one . One of the codes in this chapter (I4. Supraventricular tachycardia. However, there are several other clinical concepts that are also classified here. Among them are paroxysmal atrial tachycardia, paroxysmal junctional tachycardia, auricular tachycardia and nodal tachycardia. Another feature of statistical classifications is the provision of residual categories for . So, in the previous example, each of the tachycardia listed would have its own code. This makes nomenclatures unwieldy for compiling health statistics. Types of coding systems specific to health care include: WHO Family of International Classifications. Some of these international standards have been revised and adapted by various countries for national use. Reference classifications. In addition to the ICD and its national variants, they include: Procedure. In addition to the ICHI and ICPC, they include: Library classification that have medical components. The United States has used a clinical modification of ICD (ICD- 9- CM) for the additional purposes of reimbursement. ICD- 1. 0 was endorsed by WHO in 1. WHO Member states began using the classification system in 1. In the US, however, it has only been used for reporting mortality since 1. Because of the US delay in adopting its version of ICD- 1. ICD has a hierarchical structure, and coding in this context, is the term applied when representations are assigned to the words they represent. Classification systems such as ICD- 9- CM, ICD- 1. CM, and ICD- 1. 0- PCS group together similar diseases and procedures and organise related entities for easy retrieval. SNOMED is clinically- based, documents whatever is needed for patient care and has better clinical coverage than ICD. SNOMED CT is used directly by healthcare providers during the process of care, whereas ICD is used by coding professionals after the episode of care. SNOMED CT has multiple hierarchy, whereas there is single hierarchy for ICD. SNOMED CT concepts are defined logically by their attributes, whereas only textual rules and definitions in ICD. The National Library of Medicine (NLM) maps ICD- 9- CM, ICD- 1. CM, ICD- 1. 0- PCS, and other classification systems to SNOMED. The full value of the health information contained in an EHR system will only be realised if both systems involved in the map are up to date and accurately reflect the current practice of medicine. Together with and as an integrated part of the electronic health information systems, the coding and classification systems will be used to improve the quality and effectiveness of the medical services. For example, hypertension is represented by the code 'I1. XX. It is based on the World Health Organisation (WHO)ICD- 1. Australian Classification of Health Interventions (ACHI), Australian Coding Standards (ACS). Clinical coding is a specialised skill requiring excellent knowledge of medical terminology and disease processes, attention to detail, and analytical skills. The coder then assigns codes for these diagnoses and procedures based on ICD- 1. AM conventions and standards. This process allows hospital episodes to be grouped into meaningful categories, helping us to better match patient needs to health care resources. Statistically this information is used to keep a track of payment by results, cost analysis, commissioning, etiology studies, health trends, epidemiology studies, clinical indicators and case- mix planning. Veterinary medical coding. Animal Hospital Codes, and SNOMED. See also. Family of International Classifications. Accessed 1. 2 July 2. World Health Organization. International Classification of Diseases (ICD).^Canadian Institute for Health Information. Accessed 1. 2 July 2. New Zealand Health Information Service. Accessed 1. 2 July 2. World Health Organization - Family of International Classifications. World Health Organization. Retrieved 8 September 2. World Health Organization. Retrieved 8 September 2. Retrieved 3. 0 May 2. Community Dent Oral Epidemiol. Technical aids for persons with disabilities: Classification and terminology (ISO9. WHO. International Classification for Nursing Practice (ICNP).^https: //www. Retrieved 8 September 2. CCI.^ abhttp: //www. Snomed/snomed. Amatayakul,MBA,RHIA,CHPS,CPHIT,CPEHR& FHIMSS.(2. Electronic Health Records: A Practical Guide for Professionals and Organizations. Chicago,America: AHIMA^http: //www. CTTo. ICD1. 0Maps/en/^. Tidsskr Nor Laegeforen.
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