Question

Clinical Vocabularies You have been hearing the subject of clinical vocabularies discussed frequently at several meetings. Since the concept will impact the HIM department of your ambulatory surgical center, you recognize the need to research the subject more thoroughly to be able to articulate the needs not only of your department but also of the facility in general. 1. What vocabularies do you have to choose from? 2. What are the functions of each of these vocabularies? 3. Is the vocabulary appropriate for your setting and purposes? 4. Based on your description, which vocabulary or vocabularies would you choose? Justify your decision.

Answer 1

Clinical vocabularies are coding system that are structured list of terms which together with their defination are designed to describe the care and treatment of the patient.

Some of the vocabularies used in my setting :-

SNOMED CT

SNOMED CT or SNOMED Clinical Terms is a systematically organized computer processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting.

ICD-10

ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It is used to code a disease condition.

I would choose ICD -10-CM Coding , because it's easy to use and is more widely used in my setting .