Classification Systems Flashcards

Study Notes

MEDCIN

Proprietary clinical terminology created for electronic health record (EHR) documentation.
Developed by Peter S. Goltra in 1997 to ensure language-independent medical information management.
Capable of encoding comprehensive health records, including symptoms, history, diagnoses, and treatments.
Continuously updated and underpinning multiple EHR systems.

CCC (Clinical Care Classification System)

A former Home Health Care Classification system designed for evaluating patient resources in home health services.
Comprises two taxonomies: Nursing Diagnoses and Outcomes, and Nursing Interventions and Actions.
Originated from a project at Georgetown University School of Nursing by Virginia K. Saba and colleagues in 1991.
Facilitates research, education, and development of clinical pathways in healthcare systems.

NDC (National Drug Codes)

Universal product identifiers for frequently-prescribed drugs, part of Medicare's out-of-hospital drug reimbursement program.
The FDA owns and manages an extensive directory with over 123,000 prescription drugs.
Plays a critical role in billing, reimbursement, and public health protection.

NANDA & NIC/NOC (Nursing Interventions Classification/Nursing Outcomes Classification)

NANDA classifies nursing diagnoses, highlighting patient responses to diseases rather than disease classifications.
Recognized as a standardized nursing language by the American Nurses Association (ANA), with international adoption.
NIC covers standardized intervention classifications, promoting patient care documentation and management.
NOC measures outcomes resulting from nursing interventions, defined by unique codes for clinical information systems.

Omaha System

Developed by the Omaha Visiting Nurses Association, serving as a practice and documentation tool in home healthcare.
Comprises assessment, intervention, and outcome components to support continuity in patient care from admission to discharge.

ICF (International Classification of Functioning, Disability and Health)

Released by WHO in 2001, focusing on how individuals experience health conditions.
Classifies health-related domains including body functions, activities, and participation.
Marks a shift in emphasis from disability to health levels.

MedDRA (Medical Dictionary for Regulatory Activities)

Comprehensive dictionary used throughout drug development phases, except for animal toxicology.
Developed under the guidance of the International Conference on Harmonization (ICH).
Utilized for reporting adverse effects and features a hierarchical structure for effective categorization.

ABC Codes

Developed by ABC Coding Solutions since 1996, focusing on procedures in complementary and alternative medicine (CAM).
Aim to collect data from nontraditional healthcare provider visits, enhancing outcome comparisons.

UMDNS (Universal Medical Device Nomenclature System)

Standardized international nomenclature system for medical devices, developed by ECRI.
Classifies a wide range of medical items, supporting indexing and retrieval of device-related information.

GMDN (Global Medical Device Nomenclature)

Established by the European Committee for Standardization, managed by the GMDN Agency.
Aims to classify medical devices according to safety and performance regulations set by European Directives.

PNDS (Perioperative Nursing Data Set)

Developed by AORN to document the perioperative experience from preadmission to discharge.
Serves as a universal language for documenting patient outcomes in the perioperative setting.

RXNorm

Standard nomenclature for clinical drugs initiated by NLM to improve drug naming interoperability.
Covers prescription medications in the U.S., incorporating active ingredients and forms.
Addresses gaps in existing drug naming conventions for efficient information exchange.

LOINC (Logical Observation Identifiers, Names, and Codes)

Developed at the Regenstrief Institute, provides universal identifiers for laboratory and clinical observations.
Freely available standard designed for electronic transactions between independent systems.
Widely adopted across various sectors for effective health information exchange.

READ Codes

Known as Clinical Terms Version 3 (CTV3), established in the 1980s, primarily for primary care data.
Developed by James Read to enable data exchange and retrieval within medical records.
Gained traction in ambulatory care, contributing to standardized medical terminology in the UK.

Description

Explore the MEDCIN clinical terminology used in electronic health records. This flashcard quiz helps you understand the key concepts and applications of MEDCIN, developed to improve clinician documentation. Test your knowledge and become familiar with this important clinical database.