Peden A H
Health Information Management, University of Mississippi Medical Center, Jackson, Mississippi, USA.
Top Health Inf Manage. 2000 Nov;21(2):1-9.
Coding systems and standardized clinical terminologies are interrelated. Coding schemes can be developed for classification systems, nomenclatures, and clinical terminologies. The coding systems most commonly used in the United States lose clinical detail and cannot meet the demands of the clinical information systems needed to support the computer-based patient record, outcomes studies, or risk-adjusted comparative research. Systems using computerized encoding and structured as terminologies offer more promise of providing the needed clinical detail. Companion systems can be developed to automatically place standardized clinical terms into less granular classification systems, such as ICD-9-CM, to maintain international compatibility and to continue federal programs based on such classifications.
编码系统与标准化临床术语相互关联。可以为分类系统、术语表和临床术语制定编码方案。美国最常用的编码系统丢失了临床细节，无法满足支持基于计算机的患者记录、疗效研究或风险调整后的比较研究所需的临床信息系统的要求。使用计算机化编码并构建为术语的系统更有希望提供所需的临床细节。可以开发配套系统，以自动将标准化临床术语放入粒度较粗的分类系统中，如国际疾病分类第九版临床修订本（ICD-9-CM），以保持国际兼容性并延续基于此类分类的联邦项目。
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