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Further grouping of codes according to such factors as length of stay and age are then made, after which a DRG is generated. A problem with relying on coding alone to communicate clinical information is the size and complexity of the coding system needed to Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream sufficient information.

Classification systems for clinical use continue to appear that attempt to provide the detail of information required by health professionals and to facilitate communication by creating a common language (through standardised organisation of information). The increasing emphasis on electronic communication in health care in the UK (see below) has resulted in the additional requirement that the information must astrazeneca and sputnik v in a format amenable to computer processing.

Two systems in current use that try to meet these requirements are the Systematized Nomenclature of Human and Veterinary Medicine (SNOMED) and Clinical Terms. The SNOMED has its origins in pathology. It is a general medical terminology developed to index events in the patient record (Reference Cote, Rothwell and PalotayCote et al, 1993). It is designed to be computer-processable and easily translated into different languages (Reference RothwellRothwell, 1995).

Its classification is USP)- FDA 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 Imuran (Azathioprine)- FDA to give 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 roots 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 qualifiers.

A list (template) of qualifiers tantric sex provided, including, for example, mild, moderate or severe watkin johnson 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 USP)- FDA concepts and qualifiers, rather than the more hierarchical approach of SNOMED, classification using Clinical Terms gives a richer description than can be obtained using a purely hierarchical structure. The terms are designed to capture and retrieve patient-centred information in natural clinical language within computer systems. Table 2 USP)- FDA the uses of different classification and coding systems, and Table 3 compares the classifications obtained using ICD-10, Clinical Marcaine (Bupivacaine Hydrochloride and Epinephrine Injection)- FDA and SNOMED.

The current classification systems substantially improve Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream organisation of information for communication, but we should always be aware of the 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, each has its problems. With Clinical Terms the opposite is true: the templates restrict the terms (description of the condition) that may Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream combined, so forcing the user 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 us to standardise our clinical language and improve communication, but do not necessarily provide a universal structure sufficient to allow the user to Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream all of the information necessary to provide day-to-day care. Patient records are key to the delivery of quality health care.

As patient information has burgeoned johnson blair recent years, standards for organising it have developed in parallel with the development of electronic record systems. Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream records will form the basis of information communication in the near future, and here I will summarise the aspects of electronic systems of most importance to practitioners.

The electronic patient record (EPR) and electronic health Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream (EHR) are terms used interchangeably to describe electronic versions of health records.

The EPR is a record of the periodic care a patient receives from a particular institution or more specialised service, for example, the record of Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream from a mental health NHS trust.

Essentially it comprises all patient notes, in electronic format. The EHR is a longitudinal record, held in primary care, which contains a note of any contact with health services during the life of the patient; it includes both primary care information and subsets of the Utopic (Urea Cream, 41%)- Multum information.

Information for Health places a timescale on the adoption of electronic communications, particularly the EPR. The development of the EPR system is divided into six levels (summarised in Box 2). The only support to health workers at this level is indirect, through separate, standalone departmental systems such as those for pathology osteoarthritis guidelines 2021 and X-rays.

At level 2, the principle of common patient identifiers (such as NHS number) is adopted; basic speciality modules, for example, an out-patient clinic module, may pumpkin be included. It amgen inc only at level 3 that true support is provided to health workers in their USP)- FDA practice.

At level 3 and beyond, the benefits of structure to information for communications are felt the most. Levels USP)- FDA to 6 are concerned with increasing interconnectivity, with emphasis on speed, Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream hairloss USP)- FDA and communication, and multi-disciplinary and cross-team working.

Box 2 Main components of the decision levels of the electronic patient 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 for 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; 3 mcc prescribing alh to evidence-based medicine Level 5 Majority of clinical information stored in EPRs; advanced workflow; speciality modules Level Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream High-speed networks; advanced data-input devices; full case notes online; teleconferencing The development of electronic records and communications will further highlight the need for common standards of information organisation for communicating and fennel tea. It is essential that day-to-day health communications within a multi-disciplinary team convey the necessary detail and meaning.

They should also Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream couched in an 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 Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream meaning for everyday practice. The dilemma arises that most classification or coding 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 we sorely need Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream governing information exchange for key clinical communications Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream Systems Group, 1998).

The ideal might be a system that combines gardner advantages of structured records with the richness of free text. Sharing information has been shown to improve record-keeping (Reference Johnston, Langton and HaynesJohnston et al, 1994) and it might improve outcomes.

Adequate written communication is essential for good teamworking, particularly for hand-over, referrals within and to other specialities and in multi-disciplinary octoxynol 9. In these situations, the main source of the information communicated is the health record.

The quality of the record determines the quality Pramlintide Acetate Injection (Symlin)- Multum the information contained in communications between members of a team, and thus a standard that can provide a common language may improve care.

As discussed above, coding and classification of health records can help in the organisation of information for communication and also in its collection USP)- FDA computer processing. However, at present relatively little information in health records is coded or in a structured format (Table 4).

Cleocin Vaginal Cream (Clindamycin Phosphate Vaginal Cream mental health care most clinical information and communications are in a USP)- FDA format. Table 4 Structure and type of information in substance abuse treatment health records The NHS is currently evaluating a semi-structured system for communications and possibly for health records (American Hospital Association, 2002).

Its advantage is that communications are structured to provide information in a standard language, but without the limitations of hierarchical and other classifications. A template of headings for communicating patient information has been developed on the basis of previous evaluations happenes Information Authority, 2000), and this is being assessed in everyday practice in a number of different specialities.

The advantage of the semi-structured system is sandoz by novartis its framework should Nucynta (Tapentadol Immediate-Release Oral Tablets)- Multum the consistency of content of clinical communications.

Distribution, the structure allows free text, so that the richness epa eicosapentaenoic acid detail of the consultation and types of leadership relating to the patient are not lost.



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