Question

What is the difference between a clinical terminology, a classification and a code system? How are these three groups related? Give at least one example of the differences between the three and one example of how they are interrelated.

Answer 1

Clinical terminology is a set of standardized terms and their synonyms that records patient findings, circumstances,events and interventions with sufficient detail to support clinical care,decision support,outcomes research and quality improvement whereas Classification is a clinical vocabulary , terminology or nomenclature that lists words or phases with their meanings, provides for the proper use of clinical words as names or symbols and facilities mapping standardized terms to broader classification for administrative , regulatory , oversight and fiscal requirements.On the other hand Code system is an accumulation of numeric or alphanumeric representation or codes for exchanging or storing information.

They are interrelated to each other because without clinical terminology classification is impossible .on the other hand code system totally depends on clinical terminology and classification of diseased condition without which coding is impossible.

Example:-ICD-10-CM code for Secondary diabetic ketoacidosis is E13.10. This coding is done based on the classification of diseased condition and clinical terminology.

This shows that how clinical terminology, classification of disease is important for coding system.