The CDSS does have appropriate vocabularies to support it.
1. SNOMED ontology
SNOMED, the Systemized Nomenclature of Medicine is assembled into nineteen hierarchies. The vocabulary furthers future medical developments and supports evidence-based care (IHTSDO, 2016b). SNOMED CT usage is fundamental in the medical field because the patients, the clinicians, and the population all benefit from its usage. There is better communication if this ontology is employed within Electronic Health Records (EHRs) amongst all entities involved and information and support are provided in real time. According to (IHTSDO, 2016d), individuals benefit from this ontology because their record is always accurate and consistent information is documented during a
CYANOTIC: A patient who has cyanosis, or a slight bluish discoloration of the skin due to the presence of abnormal amounts of reduced hemoglobin in the blood
Well it looks like the low budget revolutionary nitwits of Broke-Ass Mountain are a little butt hurt this week because citizens were sending them boxes of dildos instead of the much needed french vanilla creamer they requested to sustain their rebellion. After two weeks of a sad and almost comically armed protest, it looks like "The Tree House Bandits" AKA Ammon Bundy's Oregon Militia might be calling it quits.
A current problem with SNOMED CT is concept ID. Concept IDs give a medical term (Patient or Scalpel) an ID. This language can be confusing, and when there is confusion, quality of care and higher costs of health care can occur. When concept IDs are created, there needs to be a hierarchy so that each version can be kept track of the specific relation. Commonalities in the concept IDs can create a problem with SNOMED CT; the new concept model was created to figure out how to solve the issue or make it explicit. In addition to Concept IDs, uninformative codes are another problem with SNOMED CT.
“a paperless, digital and computerized system of maintaining patient data, designed to increase the efficiency and reduce documentation errors by streamlining the process.”(Santiago, n.d., para. 1)
In today’s complex and highly competitive environment, clinicians struggle with finding a defining edge in quality of care, patient satisfaction, and affordability. To respond to these needs physicians are looking for better tools to record information, assist in clarifying issues, provide comparative results over time, become more affordable, improve workflow and procedural process, and share information with outside partnering organizations. Clinical technologies have come a long way to help answer some of these needs. These technologies have become more precise, functional, focused and mobile. They are perceived in many circles as valuable and necessary in the practice of modern medicine. Moreover, the use of clinical
SNODENT is a clinical terminology that is used with EHR’s this enables and capture the analysis, aggregation of the detailed health data. When it comes to comprehensive data recording it will Enables SNODENT’s clinicians, academics and researches to record in total details when it comes health data, when it comes to using a combination that has a standard clinical documents that is advanced by HL7 it can transcend for the care setting there are many conditions, findings that other clinical may find with in SNODENT. Recognizing codes for EHR is a subset for SNODENT which is the best choice for any clinical vocabulary for EHR Systems. The eligibility when it comes to Medicare and Medicaid is required to use SNODENT as SNOMED-CT which is required terminology for the certified EHR Systems. The benefits that can include better communication when it comes to health care providers is to improve patient care that is based on the practice, enhance data collection to evaluate that patient care outcomes and to address any complex issues to better data research and to support evidence based on the practice, being able to enhance on the public health reporting and their standard of care. The system Systematized Nomenclature of Dentistry is to classify clinical terminology for dentistry. This can be used in the connection with the Center for Medicare and Medicaid Services (CMS) Electronic Health Records (EHR) and Meaningful Use Incentives programs. Which it contains over 7000 distinct
Diagnostic coding is one of the most critical parts of medical coding. If the correct diagnostic code is not selected, a claim may be denied (Deborah Vines, 2013, pp. 88-125). Using the ICD-9-CM, diagnosis coding became mandatory for Medicare claims since the Medicare Catastrophic Coverage Act of 1988. In 1948, the ICD came under the direction of the World Health Organization, which assisted in tracking deaths and sicknesses to help make statistical assessments of international health and disease trends (Deborah Vines, 2013, pp. 88-125). Medical terminology plays a key role in proper diagnosis coding. You must be able to read and understand the physician’s documentation to identify the appropriate codes for medical conditions that pertain
When the electronic health record is coded, it can be utilized for trending, alerts (warnings or signs), health maintenance, and decision support. It can be recognized correctly and electronically distinguished by way of the computer. Document image data must have an individual to look at and understand the information. Also, codes remove uncertainties about the physician’s meaning and diagnosis. It’s very crucial and essential to document a code acknowledging the clinical data as well as to the explanation of the text. A documentation is referred to as codified when the code is saved in the patient’s electronic health record. A codified electronic health record is more beneficial because it classifies the medical provider’s results or treatments.
Electronic Health Records: Understanding and Using Computerized Medical Records, 2nd Edition, by Richard Garlee, Published by Prentice Hall, 2012, Pearson Education, Inc.
The healthcare industry is in the midst of a major change from paper based medical record keeping to electronic medical record keeping. As part of the American Recovery and Investment Act of 2009, the Health Information Technology for Economic and Clinical Health (HITECH) Act was passed (Office of the National Coordinator for Health Information Technology, 2014). HITECH is the U.S. Government’s first major contribution to the change from paper to electronic health information technology by setting meaningful use incentive program for Medicare and Medicaid providers that met certain requirements. Healthcare professionals that meet the meaningful use criteria will be awarded financially, and those that don’t meet the 2015 guideline will be penalized. We live in an electronic world of instant access to information and by adopting health information technology we give providers better and easier access to more information which in turn allows them to make a more informed diagnosis and treatment plan for the patient. The electronic health record (EHR) is part of the new information technology. According to the Office of the National Coordinator for Health Information Technology (2014.), EHR’s provide many benefits such as improvement in the quality of patient care; improvement in the coordination of patient care; more accurate diagnosis and better outcomes; a higher level of patient participation in their own care; and cost savings for the practice
“… longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting”. Included in this information are patient demographics… reports. The EHR automates and streamlines the clinician 's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, and related activities directly or indirectly via interface—including evidence-based decision support, quality management, and outcomes reporting.”(GAO, 2010)
Standardized terminologies were created to be use within the electronic health record (EHR). “Standardized terminologies are
When Belinda was twelve, her father died of a stroke while he danced with her, after battling through compulsive behaviors, depression, and anxiety she was ultimately hospitalized. Velia, age eleven, never met her dad. Confused and at times rejected by her mother, she became involved with drugs and binge eating episodes. After terminating treatment she had a baby out of wedlock like her mother. Maria when she was thirteen was having sexual relations with her peers and was called various names such as “whore” at school. She deeply longed to meet her biological father from an early age (Kestenbaum & Stone, 1976). These are a few of the devastating stories of real women who had to undergo various psychological treatments to deal with their behavioral
When it comes to the violent victimization of children, children should have the right to be protected from victimization. Although the media focus on the victimization of children, children are increasingly becoming victims of violent crimes and neglect. Humphrey & Schmalleger stated, "About 1 in 10 homicide victims in the United States is 18 years of age or younger, about one third are females, and 47% are black" (Humphrey and Schmalleger, 2012, p. 89). One sociocultural change that would reduce the violent victimization of children is preventing any physical, sexual, and any other abuse of children that would require an extremely wide range approach to cease any level of sociocultural. I truly believe that any family structure could prevent
In Radiology, there is not too many codes used within the department. However, when a doctor orders an exam, often times they