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). Read the rest of this entry »
Electronic Medical Records and Coding Systems
5 05 2010Comments : 26 Comments »
Tags: coding systems, College of American Pathologists, Cornell, David Brailer, Electronic Health Record Association, electronic medical records, electronic records, EMR software, General Accounting Office of the Information Management and Technology Division, Harvard, International Health Terminology Standards Development Organization of Denmark, interoperability, Johns Hopkins, MEDCIN, medical billing, National Coordinator for Health Information Technology, National Library of Medicine, physician’s medical language, SNOMED-CT, Systematized Nomenclature of Medicine-Clinical Terms, UNC Health Sciences Library, United States Department of Defense, US Department of Health and Human Services
Categories : School Research Papers