Clinical Classifications and Terminologies

Clinical Classifications and Terminologies

• American Medical Association (AMA): National organization for physicians that disseminates scientific knowledge, informs on health legislation, and advocates for the medical profession at the federal level.

• American Society for Testing and Materials (ASTM): A national body dedicated to creating standards for materials, products, systems, and services.

• Breast Imaging Reporting and Data System Atlas (BI-RADS): A standardized framework for terminology and reporting in breast imaging, covering mammography, ultrasound, and MR assessments.

• Clinical Care Classification (CCC): Comprises two taxonomies that standardize documentation for nursing diagnoses and interventions across various healthcare settings.

• Clinical Terminology: Standardized terms and synonyms used to document patient findings and interventions, supporting care, decision making, research, and quality improvements.

• College of American Pathologists (CAP): An organization promoting excellence in pathology and laboratory medicine for patients, pathologists, and the public.

• Community of Practice (CoP): A network of individuals focused on exploring clinical terminologies and vocabularies.

• Concept: Defined as a unit of knowledge or thought shaped by specific characteristics.

• Consolidated Health Informatics (CHI): Initiative for adopting interoperability standards across federal health agencies.

• Context: Descriptive text that contextualizes a concept or designation.

• Current Dental Terminology (CDT): A dental procedure coding system, maintained by the American Dental Association (ADA), originally known as the Uniform Code on Dental Procedures and Nomenclatures until 1990.

• Current Procedural Terminology (CPT): A coding system developed by the AMA for outpatient procedure coding, updated annually on January 1.

• Digital Imaging and Communications in Medicine (DICOM): A standard for digital image formats and picture archiving communications systems.

• Emergency Care Research Institute (ECRI): Collaborates with the FDA on a Universal Medical Device Nomenclature project aimed at standardizing practices.

• Environmental Protection Agency (EPA) Substance Registry System (SRS): Establishes interoperability standards for identifying chemicals and substances regulated by the EPA.

• European Committee for Standardization (CEN): Facilitates trade within Europe by developing European Standards and technical specifications.

• Extensibility: The ability for vocabulary to be expanded by users or developers.

• Framework: A foundational structure upon which systems or processes can be built.

• Global Medical Device Nomenclature (GMDN): A set of internationally accepted terms for describing and categorizing medical devices.

• Granularity: Refers to the precision of access control over who can view and manipulate data across various databases and fields.

• Healthcare Common Procedure Coding System (HCPCS): Classification system that identifies healthcare procedures and equipment for smooth operational management.