36 Questions
Which of the following is a key characteristic of a code system?
It is an accumulation of terms and codes for exchanging or storing information
What is the primary purpose of the International Classification of Diseases for Oncology, Third Edition (ICD-O-3)?
To report the topography and morphology of neoplasms to cancer registries
What is the primary use of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)?
To provide a classification for mental disorders and guide clinical assessments and treatment planning
Who is primarily responsible for assigning codes in the Logical Observation Identifiers, Names, and Codes (LOINC) system?
No one assigns codes, as LOINC is implemented in software applications
Which of the following coding or classification systems is used to report cancers to state and national registries?
ICD-O-3
Which of the following coding or classification systems is primarily used for the exchange or storage of general medical information?
A code system, as defined in the text
What is the definition of nomenclature?
A system of names that follows preestablished conventions
Which term describes an accumulation of terms and codes for exchanging or storing information?
Code system
What is the primary use of clinical terminologies and code systems?
For clinical decision support
Who historically used medical content classification systems to identify causes of death?
Government agencies
In the healthcare industry, what does EHR data primarily contain?
Granular clinical information
What is the significance of detailed clinical content in data capture?
To support clinical decision making
What is the primary purpose of clinical terminologies like SNOMED CT?
To standardize clinical phrases for documentation and information sharing
What is the role of reference terminologies in clinical terminologies?
To provide common semantics and support meaning-based retrieval
Which of the following is true about SNOMED CT identifiers?
They are unique integers that do not carry any semantic meaning
What is the purpose of the 'Relationships' component in SNOMED CT?
To connect concepts and establish relationships between them
Which of the following is an example of a clinical terminology?
SNOMED CT
Who is primarily responsible for implementing and using clinical terminologies like SNOMED CT?
Software application developers
Which of the following coding or classification systems is used to report cancers to state and national registries?
ICD-O-3
What is the primary use of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)?
To classify and diagnose mental disorders
Which term describes an accumulation of terms and codes for exchanging or storing information?
Code system
What is the primary purpose of clinical terminologies like SNOMED CT?
To provide a structured way to represent clinical content and support data capture, retrieval, and exchange
Which of the following is an example of a clinical terminology?
SNOMED CT
In the healthcare industry, what does EHR data primarily contain?
Laboratory and clinical variables
What is the primary purpose of clinical terminologies like SNOMED CT?
To provide a standardized way to represent clinical data for documentation and reporting
Which of the following coding or classification systems is primarily used for the exchange or storage of general medical information?
LOINC
What is the significance of detailed clinical content in data capture?
It enables semantic interoperability and health information exchange
Who is primarily responsible for implementing and using clinical terminologies like SNOMED CT?
Software application developers
What is the primary use of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)?
To provide a standardized system for the classification of mental disorders
In the healthcare industry, what does EHR data primarily contain?
Coded data from clinical terminologies like SNOMED CT
Which data set primarily contains detailed clinical content?
EHR data
What is the primary purpose of using aggregate data from classifications and code systems?
Billing and payment
Which type of standardized system is used to encode clinical data in healthcare?
Clinical terminology
What characteristic distinguishes a classification from a terminology?
Classifications organize terms mono-hierarchically
Which group historically used medical classification systems to identify causes of death?
Public health agencies
What defines a code system according to the definitions provided?
An accumulation of terms and codes
Study Notes
- ICD-O-3 is a classification used by tumor registries to report the topography and morphology of neoplasms, providing greater detail than ICD-10.
- DSM-5 is a classification for mental disorders used in clinical assessments, treatment plans, and communication between healthcare providers.
- LOINC is a system for identifying health measurements and observations, implemented in software applications, standardizing names and codes for laboratory and clinical variables.
- Clinical terminologies, classifications, and code systems are essential in healthcare for capturing data at a granular level for primary (clinical decision support) and secondary (billing and payment) uses.
- SNOMED CT is a clinical terminology used for documentation and reporting, providing a granular level of clinical data capture, supporting interoperability, and standardizing clinical phrases and information exchange.
Test your knowledge on clinical terminologies, classifications, and code systems as defined in Chapter 5 of 'Health Information Management Technology: An Applied Approach, Sixth Edition'. Explore key terms such as vocabulary, nomenclature, classification, code, and code set.
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