Domain 1: Chapter 5 - Clincial Classifications, Vocab, Terms, & Standards

Clinical Care Classification (CCC)

"Two interrelated taxonomies, the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions, that provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other healthcare settings"

MeSH (Medical Subject Headings)

-National Library of Medicines controlled vocabulary thesaurus -A way to identify various words that mean the same thing and "connect them" to a heading -uses a hierarchical structure that permits searching at various levels of specificity -Automatic Term Mapping (ATM)

Lexicon

1. the vocab used in a language or subject area or by a particular speaker 2. a collection of words or terms and their meanings for a particular domain, used in healthcare for drug terms

RxNorm

A clinical drug nomenclature developed by the Food and Drug Administration, the Department of Veterans Affairs, and HL7 to provide standard names for clinical drugs and administered dose forms

Clinical vocabulary

A formally recognized list of preferred medical terms.

Healthcare Common Procedure Coding System (HCPCS)

A medical code set that identifies healthcare procedures, equipment, and supplies for claim submission purposes. It has been selected for use in the HIPAA transactions. HCPCS Level I contains numeric CPT codes which are maintained by the AMA. HCPCS Level II contains alphanumeric codes used to identify various items and services that are not included in the CPT medical code set. These are maintained by HCFA, the BCBSA, and the HIAA. HCPCS Level III contains alphanumeric codes that are assigned by Medicaid state agencies to identify additional items and services not included in levels I or II. These are usually called "local codes", and must have "W," "X," "Y," or "Z" in the first position. HCPCS Procedure Modifier Codes can be used with all three levels, with the WA-ZY range used for locally assigned procedure modifiers (CMS 2013)

clinical terminology

A set of standardized terms and their synonyms that record patient findings, circumstances, events, and interventions with sufficient detail to support clinical care, decision support, outcomes research, and quality improvement

terminology

A set of terms representing the system of concepts of a particular subject field; a clinical terminology provides the proper use of clinical words as names or symbols

Clinical Document Architecture (CDA)

An HL7 XML-based document markup standard for the electronic exchange model for clinical documents (such as discharge summaries and progress notes)

ICD-10-CM

International Classification of Diseases, 10th Revision, Clinical Modification

ICD-11

International Classification of Diseases, Eleventh Revision developed to integrate

ICD-10-PCS

International Classification of Diseases, Tenth Revision, Procedure Coding System

IHTSDO

International Health Terminology Standards Development Organization

ICPC-2

International classification of primary care

Semantic interoperability

Mutual understanding of the meaning of data exchanged between information systems

multiaxial

The ability of a nomenclature to express the meaning of a concept across several axes

Continuity of Care Document (CCD)

The result of ASTM's Continuity of Care Record standard content being represented and mapped into the HL7's Clinical Document Architecture specifications to enable transmission of referral information between providers; also frequently adopted for personal health records

NLM (National Library of Medicine)

The world's largest medical library; located in Maryland

clinical classification

a clinical vocab, term, or nomenclature that lists words or phrases with their meanings; provides for the proper use of clinical words as names or symbols; & facilities mapping of standardized terms

LONIC (logcial obs identifiers names and codes)

a database protocol developed by the regenstrief institute for health care aimed at standardizing lab & clinical codes for use in clinical care, outcomes mgmt, & research that enable exchange & aggregation of e health data from many independent sys

Diagnostic and Statistical Manual of Mental Disorders (DSM)

a nomenclature developed by the american psy association to standardize the diagnostic process for pts with psy disorders

MEDCIN

a proprietary clinical terminology developed as a point-of-care tool for electronic medical record documentation at the time and place of patient care

Current Dental Terminology (CDT)

a reference manual maintained and updated annually by the american dental association (ADA); included in the manual is the code on dental procedures and nomenclature (thecode), which is a classification system for dental treatment procedures and services

reference terminology

a set of concepts & relationships that provide a common reference point for comparisons & the aggregation of data about the entire healthcare process, recorded by multiple different individuals, systems, or institutions

relationship

a type of connection between two terms

concept

a unique unit of knowledge or thought created by a unique combination of characteristics

Topography

code that describes the site of origin of the neoplasm and uses the same 3 and 4 character categories as in the neoplasm section of the second chapter of ICD-10; description of a part of the body

PMRI (patient medical record info)

information in which SNOMED CT is part of a core set of terminology

ToC (transitions of care initiative)

one of the projects of the standards and interoperability (S&I) framework, this initiative's charter states that the exchange of clincial summaries is hampered by ambigous common definitions of what data elements must be at a min be exchanged, how they must be encoded, and how those common semantic elements

clinical information model

outcome of the transitions of care (ToC) initiative consisting of the unambiguous, clinically-relevant definitions of the core data elements that should be included in care transitions

UMLS (Unified Medical Language System)

provides a way to integrate biomedical concepts from a variety of sources to show their relationships. process allows links to be made between different info systems for purposes such as electronic health record systems. Specific interest to HIM mgr is medical vocabularies such as the ICD-9-CM, CPT, and the HCPCS are among the items included.

functional interoperability

refers to sending messages between computers with a shared understanding of the structure and format of the message

Basic interoperability

relates to the ability to successfully transmit and receive data from one computer to another

National drug codes (NDC) directory

sets forth the extent to which medicare will cover specific services, procedures, or technologies on a national basis. Medicare contractors are required to follow NCDs.

nomenclature

technical names or naming system in an art or science

interface terminology

terminology concerned w/ facilitating clinican doc within the standardized structure needed for e health record

Interoperability

the capability of two or more computer systems to share data and resources, even though they are made by different manufacturers

SNOMED-CT (Systematized Nomenclature of Medicine Clinical Terms)

the most comprehensive, multilingual clincial healthcare terminology in the world. Contributes to the improvement of the pt care by underpinning the development of the e health record that record clinical info in ways that enable meaning-based retrieval

Morphology

the science of structure and form of organisms without regard to function

Current Procedural Terminology (CPT)

the standardized classification system for reporting medical procedures and services