ChristmanWK3 - Coding Systems

ChristmanWK3 - Coding Systems - Christman 1 Tiffany...

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Christman 1 Tiffany Christman/FTMYERS Instructor Hazel HHSM/Research Week 3 2 May 2010 Describe the various coding systems used in electronic medical records. What are the challenges for having so many different coding systems? If you’ve ever had to utilize a computer software program to translate a document from one language to another, you have probably noticed that some information is lost in that translation process. Words may be out of place, grammar mussed, and the entire context of the intended message could be lost. This is an example of the challenges faced when coding a physician’s visit with a patient into an electronic document. There is the obvious need to use these translation methods for electronic records, thus organizations, medical staff and software developers are continually working to improve the translation process and reduce these issues. The General Accounting Office of the Information Management and Technology Division reported the need for a standardized coding system due to the frequent use in medical practices of the same term for various ailments; such as describing hepatitis as a liver inflammation (GAC, 8). “The use of different terms and codes…to indicate the same condition…complicates retrieval and reduces data reliability and consistency.” (GAC, 9) Coding systems for electronic record keeping differs from coding systems utilized in medical billing primarily because billing code sets are too generalized to offer specific information about a condition or diagnosis (Gartee, 64). Ideally, information entered into an electronic medical record should be standardized amongst all facilities, no matter the software system or user which is the basis for using a universal system of codes (Bowman).
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Christman 2 Systematized Nomenclature of Medicine-Clinical Terms, referred to as SNOMED-CT, is one of the coding systems accepted for electronic records (National Libraries). SNOMED began as a language developed for use in describing pathology specific issues, developed by the College of American Pathologists, yet it has been refined over time to become an international medical coding standard, maintained by the International Health Terminology Standards
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ChristmanWK3 - Coding Systems - Christman 1 Tiffany...

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