Chapter 5 Clinical Classification, Vocabularies, Terminologies, and Standards

Question 1

Basic Interoperability

Answer 1

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

Question 2

Clinical Care Classification (CCC)

Answer 2

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

Question 3

Clinical Classification

Answer 3

A clinical vocabulary, terminology, or nomenclature that list words or phrases with their meanings; provides for the proper use of clinical words as names or symbols; facilitates mapping of standardizes terms to broader classification for administrative, regulatory, oversight, and fiscal requirements Example: ICD-10-CM

Question 4

Clinical Documentation Architecture (CDA)

Answer 4

An HL7 XML-based document markup standard for the electronic exchange model for clinical documents (such as discharge summaries and progress notes). The implementation guide contains a library of CDA templates, incorporating and harmonizing previous efforts from HL7, Integrating the Healthcare Enterprise (IHE), and Health Information Technology Standards Panel (HITSP). It includes all required CDA templates for Stage I Meaningful Use, and HITECH final rule

Question 5

Clinical Information Model (CIM)

Answer 5

Consisting of unambiguous, clinically-relevant definitions of the core data elements that should be included in care transitions.

Question 6

Clinical Terminology

Answer 6

A set of standardized term 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. Example: SNOMED CT

Question 7

Clinical Vocabulary

Answer 7

A formally recognized list of preferred medical terms

Question 8

Concept

Answer 8

The most granular unit within a terminology defined as a signal clinical meaning identified by a unique numeric identifier.

Question 9

Continuity of Care Document (CCD)

Answer 9

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 transmissions of referral information between providers; also frequently adopted for personal health records

Question 10

Continuity of Care Record (CCR)

Answer 10

Is a core data set of the most relevant administrative, demographic, and clinical information about a patient’s health care, covering one or more healthcare encounters. It provides a means for one health care practitioner, system, or setting to aggregate all of the pertinent data about a patient forward it to another practitioner, system, or setting to support the continued care

Question 11

Current Dental Terminology (CDT)

Answer 11

A reference manual maintained and updated annually by the American Dental Association.

Question 12

Current Procedural Terminology (CPT)

Answer 12

Provides a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby serves as an effective means for reliable nationwide communication among physicians, patients, and third parties.

Question 13

Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM5)

Answer 13

A handbook used by professionals as a guide to diagnose mental disorders and was first published by the American Psychiatric Association (APA).

Question 14

Functional Interoperability

Answer 14

Sending messages between computers with a shared understanding of the structure and format of the message.

Question 15

Healthcare Common Procedure Coding System (HCPCS)

Answer 15

Used to report services and supplies primarily for reimbursement purposes in the outpatient or ambulatory setting.

Question 16

Interface Terminology

Answer 16

Terminology concerned with facilitating within the standardized structure needed for an electronic health record.

Question 17

International Classification Disease (ICD)

Answer 17

Facilitates the storage and retrieval of diagnostic information and serves as the basis for compiling mortality and morbidity statistics reported by WHO members.

Question 18

International Classification Disease, 10th Revision, Clinical Modification (ICD-10-CM)

Answer 18

For reporting of morbidity data and reimbursement in the United States.

Question 19

International Classification Disease, 10th Revision, Procedure Coding System (ICD-10-PCS)

Answer 19

The coding classification system that replaced ICD-9CM, volume 3, on October 1, 2015. ICD-10-PCS has 16 sections and contains significantly more procedure codes than ICD-9-CM, providing the ability to code procedures with greater level specificity.

Question 20

International Classification Disease, 11th Revision (ICD-11)

Answer 20

Designed to include linkages to standardized healthcare terminologies to facilitate processing and use of the data for a variety of purposes such as research

Question 21

International Classification Disease for Oncology, 3rd edition (ICD-O-3)

Answer 21

A system used for classifying incidences of malignant disease

Question 22

International Classification of Primary Care (ICPC-2)

Answer 22

Classification used for coding the reasons of encounter, diagnoses, and interventions in an episodeof-care structure

Question 23

International Classification on Functional, Disability, and Health (ICF)

Answer 23

Classification of health and health-related domains that describe body functions and structures, activities, and participation

Question 24

International Health Terminology Standards Development Organization (IHTSDO)

Answer 24

An international nonprofit organization based in Denmark that maintains and distributes the Systemized Nomenclature of Medicare-Clinical Terminology

Question 25

Interoperability

Answer 25

The ability to exchange information between computer systems

Question 26

Lexicon

Answer 26

The listings of words or expressions in a language (terminology) and information about the language such as definitions, related principles, and description of (grammatical) structure.

Question 27

Logical Observation Identifiers Names and Codes (LOINC)

Answer 27

A database protocol developed by the Regenstrief Institute of Health Care aimed at standardizing laboratory and clinical codes for use in clinical care, outcomes management, and research that enables exchange and aggregation of electronic health data for many independent systems

Question 28

Mapping

Answer 28

A function that allows for the reuse of data captured for one purpose to be used for other purposes.

Question 29

MEDICIN

Answer 29

A proprietary clinical terminology owned and maintained by Medicomp Systems.

Question 30

Medical Subject Headings Database (MeSH)

Answer 30

The NLM’s controlled vocabulary thesaurus consisting of terms naming descriptors in a hierarchical structure that permits searching at various levels of specificity.

Question 31

Morphology

Answer 31

Describes the characteristics of the tumor itself, including cell type and biologic activity.

Question 32

Multiaxial

Answer 32

(five axes) The coding system for the documentation of diagnosis

Question 33

National Drug Codes directory (NDC)

Answer 33

Developed by the FDA to serve as a universal product identifier for human drugs.

Question 34

National Library of Medicine (NLM)

Answer 34

To facilitate the development of computer systems that behave as if they “understand” the meaning of the language of biomedicine and health. The ULMS provides data for system developers as wells as search and report functions for less technical users.

Question 35

Nomenclature

Answer 35

A recognized system of terms used in a science or and art that follows preestablished naming conventions Example: HL7

Question 36

Patient Medical Record Information (PMRI)

Answer 36

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

Question 37

Reference terminology

Answer 37

A set of concepts and relationships that provides a common reference point for comparison and aggregation of data about the entire healthcare process, recorded by multiple different individuals systems, or institutions.

Question 38

Relationship

Answer 38

Describe how the concepts within SNOMED CT are linked to another.

Question 39

RxNorm

Answer 39

A standardized nomenclature for clinical drugs that provides information on a drug’s ingredients, strengths, and form in which it is to be administered or used.

Question 40

Semantic Interoperability

Answer 40

Similar to HL7 in that the information being transmitted is understood

Question 41

Systemized Nomenclature of Medicine-Clinical Terminology (SNOMED CT)

Answer 41

The most comprehensive, multilingual clinical healthcare terminology in the world. SNOMED CT contributes to the improvement of patient care by underpinning the development of electronic health records that record clinical information in ways that enable meaning-based retrieval

Question 42

Systemized Nomenclature of Medicine-Reference Terminology (SNOMED RT)

Answer 42

In 1997, the College of American pathologist worked with a team of physicians and nurses from the Kaiser Permanente to begin development of SNOMED RT, which came to be recognized as a reference terminology by the inclusion of an elementary mapping to ICD-9-CM

Question 43

Terminology

Answer 43

A set of terms representing a system of concepts.

Question 44

Topography

Answer 44

The south of origin of the neoplasm and uses the same three-and four-character categories as in the neoplasm section of second chapter of ICD-10.

Question 45

Transition of Care initiative (ToC)

Answer 45

The exchange of clinical summaries is hampered by ambiguous, clinically-relevant definitions of the core data elements that should be included in care transitions.

Question 46

Unified Medical Language System (UMLS)

Answer 46

A program initiated by the National Library of medicine to build an intelligent, automated system that can understand biomedical concepts, words, and expressions in their interrelationships; includes concepts in terms from many different source vocabularies