Author Question: ______________________________ is a globally recognized controlled health care vocabulary that ... (Read 28 times)

Chelseaamend · **on:** Jul 7, 2018

___________________ ___________ is a globally recognized controlled health care vocabulary that provides a common language for electronic health applications.

Fill in the blank(s) with correct word

Question 2

Terminologies can be incorporated within the electronic health record (EHR) thereby improving practice. Which of the following are considered uses for this technology in health care? Select all that apply.

1. Classification
2. Reference
3. Point of care
4. Coding
5. Denial of claims

jxjsniuniu · **Reply #1 on:** Jul 7, 2018

Answer to Question 1

SNOMED CT
Rationale : SNOMED CT is a globally recognized controlled health care vocabulary that provides a common language for electronic health applications. SNOMED CT is SNOMED CT enables a consistent way of capturing, sharing, and aggregating health data across specialties and sites of care. The use of SNOMED CT within electronic health records provides interoperable data collection that can be analyzed and used in the implementation of evidence-based practice, decision support rules, reporting of quality measures and administrative billing.
Global Rationale:

Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub: Management of Care
Nursing/Integrated Concepts: Communication and Documentation
Learning Outcome:

Answer to Question 2

2,3
Rationale: Terminologies are used two different ways within EHR systems first, as a reference terminology and second, as a point-of-care terminology. A reference terminology consists of a set of concepts with definitional relationships. A point-of-care terminology, frequently referred to as an interface terminology, is what the clinicians see on the screen and consists of terms with which clinicians are familiar.