Just-in-time coding of the problem list in a clinical environment.
- 1 January 1998
- journal article
- p. 280-4
Abstract
Clinically useful problem lists are essential to the CPR. Providing a terminology that is standardized and understood by all clinicians is a major challenge. UNMC has developed a lexicon to support their problem list. Using a just-in-time coding strategy, the lexicon is maintained and extended prospectively in a dynamic clinical environment. The terms in the lexicon are mapped to ICD-9-CM, NANDA, and SNOMED International classification schemes. Currently, the lexicon contains 12,000 terms. This process of development and maintenance of the lexicon is described.This publication has 8 references indexed in Scilit:
- Phase II Evaluation of Clinical Coding Schemes: Completeness, Taxonomy, Mapping, Definitions, and ClarityJournal of the American Medical Informatics Association, 1997
- Patient Core Data Set. Standard for a longitudinal health/medical record.1997
- Toward standardization of health information.1997
- Clinical terminologies and computer-based patient records.1997
- Health status measurement in computer-based patient record systems.1997
- Review Paper: Coding Systems in Health CareMethods of Information in Medicine, 1996
- The Content Coverage of Clinical ClassificationsJournal of the American Medical Informatics Association, 1996
- Medical Records That Guide and TeachNew England Journal of Medicine, 1968