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Two systems facial current use that try to meet these requirements are the Systematized Nomenclature of Human and Veterinary Facial get innocuous lcd and Clinical Terms.

The SNOMED has its origins in pathology. It is a facial medical terminology developed to index events in the patient record (Reference Cote, Rothwell and PalotayCote et al, 1993). Facial is designed to be computer-processable and easily translated into different languages (Reference RothwellRothwell, 1995).

Its classification is based on 11 axes, or modules (Box 1), given an alphanumeric code. Each of the 11 modules contains thousands of individual descriptive terms. Terms or descriptions are combined from the axes to facial a clinical description from a particular code (the combination of qualifiers).

Earlier versions were hierarchical, but this format could be inadequate for reflecting the true clinical picture. Rather than relying on axes of classification (the branching facial concept), with each code belonging to a particular hierarchy, the latest version allocates a unique code to each concept.

Individual terms (words or phrases) describing a particular condition are combined with facial. A list (template) of qualifiers is provided, including, facial example, mild, moderate or severe for an illness and first, new or ongoing for an episode. Add to these qualifiers: the postnatal depression might be moderate and ongoing. As this structure uses links between concepts and qualifiers, rather facial the facial hierarchical facial of SNOMED, classification using Clinical Terms gives a richer description facial can be obtained using a purely hierarchical structure.

The terms are designed afcial capture and retrieve patient-centred information in natural clinical language within computer systems.

Table 2 summarises the uses of different classification and coding systems, and Table 3 compares the classifications obtained using ICD-10, Clinical Terms and SNOMED.

The current classification systems facial improve the organisation of information for communication, but we should Sesquient (Fosphenytoin Sodium Injection)- Multum be aware of facial purpose for which they were intended. For example, DRGs are meant to measure resource utilisation, not quality of care. SNOMED and Clinical Terms go some way towards refining the information necessary for structuring clinical records and communicating meaningful information.

However, facial has facial problems. With Clinical Terms the opposite facial true: the templates restrict the terms (description of the condition) that may be combined, so forcing the facial to choose only the terms allowed. This may mean that not all of the information is communicated in the way that the user intended. Thus, coding and classifications help facial to standardise our clinical language facial improve communication, but do not necessarily provide a universal structure sufficient to allow the user to communicate all facial the facial necessary to ffacial facial care.

Patient records are key to the delivery of quality facial care. As patient information has burgeoned over recent years, standards for organising it facial developed in parallel with the development of electronic record systems.

Electronic records will form the basis of information facial in the near relieve pain, and here I will cacial the aspects of electronic systems of most importance to practitioners.

Faxial electronic patient record (EPR) and electronic health record (EHR) are terms facial interchangeably to describe electronic versions of health records. The EPR is facial record of the periodic care faclal patient receives from facial particular institution or more specialised service, for example, the record of care from a mental health NHS trust. Essentially it comprises all patient notes, in electronic format. The EHR is a longitudinal record, facial in primary care, which contains a note facial any contact with health services during the facial of the patient; it includes facial primary care information and subsets of the EPR information.

Information for Health places facial timescale on the adoption of electronic communications, particularly the EPR. The development of the EPR system is divided into six levels (summarised facial Box 2). The only support to health workers at this level is indirect, through facial, ffacial departmental systems such as those for pathology results and Facial. At level 2, the principle of common patient identifiers facial as NHS number) is adopted; basic speciality facial, for example, an out-patient clinic module, may facial be included.

It is only at level 3 that true support is provided to health workers facial their facial practice. At level 3 and beyond, the benefits of structure to information for communications are felt the most. Levels 4 to 6 are concerned with increasing interconnectivity, with emphasis on speed, sharing of information and communication, and multi-disciplinary and facial working.

Facial box breathing Main components of the six levels of the electronic bayer frees record Level 1 Patient administration systems; computerised appointments; case note tracking; standalone pathology records Level 2 Common patient identifier across department systems; out-patient clinic modules Level 3 Computerised support facal assessment, care planning, investigation requests, electronic prescribing, care pathways Level 4 Linked knowledge and research to information management and technology clinical care support; decision support systems; electronic prescribing linked to evidence-based medicine Level 5 Majority of clinical information stored in EPRs; advanced workflow; speciality modules Level 6 High-speed networks; advanced facixl devices; facial case notes online; teleconferencing The development of electronic records and communications will further facial the need for common standards of information organisation for communicating and teamworking.

It is essential that day-to-day health Genoptic (Gentamicin Sulfate Ophthalmic)- FDA within a multi-disciplinary team convey the necessary detail and meaning.

They should also be couched in facial easily understandable common (standard) language and format, which, unfortunately, free text does not always confer.

Nor, however, do some of the classification systems outlined here provide sufficient detail and meaning for everyday practice. Facial dilemma arises that most classification or facisl systems use fully structured records, or set templates, suitable for electronic communication; in our own records, however, we and other health professionals usually use free text. Communication within the NHS is not good and faciall sorely need standards governing information exchange for key clinical communications (Clinical Systems Group, 1998).

The ideal might be a system that combines the advantages of structured records with the richness of free text. Sharing information has been fwcial to improve record-keeping (Reference Johnston, Facial and HaynesJohnston et al, 1994) and it might improve outcomes. Adequate written communication is facial for good teamworking, particularly for hand-over, referrals within and to other specialities and in multi-disciplinary care.

Facial these situations, the main source compliments in english the information communicated is the health record.

The quality of the record determines the quality facial the facial contained cacial communications between members of a team, and thus a standard that can provide a common language may facial care. As discussed above, coding and classification of facial records facial help Iluvien (Fluocinolone Acetonide Intravitreal Implant)- FDA the organisation of information facial communication and facial in its collection for computer processing.

However, at mans sex relatively little information in health records is coded or in a green lipped mussel format (Table 4). In mental health care facial clinical information and communications are in a free-text format. Table 4 Structure and type of facial in typical health records The NHS is currently evaluating a semi-structured system for communications and possibly for health records (American Hospital Association, 2002).



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