Author Question: A classification system is used to categorize the details of the clinical encounter. Which of the ... (Read 16 times)

jace · **on:** Jul 7, 2018

A classification system is used to categorize the details of the clinical encounter. Which of the following does a classification system not do?

1. Group data to determine costs and outcomes of treatment
2. Captures the level of detail necessary to document specific items at the point of care
3. Provides data to consumers on costs and outcomes of treatment options
4. Used in the collection and reporting of health statistics

Question 2

Clinical terminologies consist of concepts that support which of the following facets of health care? Select all that apply.

1. Diagnostic studies
2. History and physical examinations
3. Visit notes
4. Ancillary department information
5. Outcomes measures

canderson530 · **Reply #1 on:** Jul 7, 2018

Answer to Question 1

2
Rationale: A classification system is used to categorize the details of the clinical encounter. It does not capture the level of detail necessary to document specific items at the point of care. Classifications consist of mutually exclusive categories that can be used for specific purposes. An example would be to group data to determine costs and outcomes of treatment. A classification system provides data to consumers on costs and outcomes of treatment options. They are used in the collection and reporting of health statistics. The International Classification of Diseases (ICD), which is a classification system, does not consist of definitions or defining relationships between terms.

Answer to Question 2

1,2,3,4,5
Rationale: Clinical terminology enables the capture of data at the level of detail necessary for patient care documentation and is used to describe health conditions and health care activities (ISO/IEC 17115, 2007). Clinical terminologies consist of concepts that support diagnostic studies, history and physical examinations, visit notes, ancillary department information, nursing notes, assessments, flow sheets, vital signs, and outcome measures. A clinical terminology can be mapped to a broader classification system for administrative, regulatory, and fiscal reporting requirements (Giannangelo, 2010, p. 3).