Endangered Medical Record: Ensuring Its Integrity in the Age of Informatics / Edition 1

Endangered Medical Record: Ensuring Its Integrity in the Age of Informatics / Edition 1

by Vergil N. Slee, Debora A. Slee, H. Joachim Schmidt

Product Details

Tringa Press
Publication date:
Edition description:
New Edition
Product dimensions:
7.50(w) x 9.25(h) x (d)

Table of Contents

List of Figuresv
Section 1Overview
1Four Serious Flaws in Our Health Information System3
Your Personal Medical Record5
Code-Dependency in Health Information8
The "Four Flaws"--Where the Problems Are12
The Solutions: Living With "Code-Dependency"26
The Time Challenge34
A Great Opportunity41
Section 2History & Background
Medical Records, Coding, and Healthcare Classification43
2Primer on Medical Records45
Formation & Contents46
Uses of Medical Record Information50
Health Information Professionals53
The Electronic Medical Record (EMR)60
3Expression of Clinical Concepts71
Types of Language71
Uniformity in Clinical Language77
Language Can't--and Shouldn't--Be Controlled97
4Retrieval of Medical Record Information99
Access to Information100
Hospital Discharge Abstract Systems103
5Codes & Coding117
The Code: An Information "Identifier"118
How Classifications Get Their Codes121
Coding Processes122
Maintaining Data Integrity130
6Classifications & Classifying133
The Classification: An Information "Organizer"134
Attributes of a Classification135
Patient Information for Classifications139
The Process of Classifying144
7Diagnosis Classifications149
The Early Years Using SNDO151
The International Classification of Diseases155
The Tenth Revision of ICD166
8Procedure Classifications175
Procedure Classifications for Hospital Use176
Procedure Classifications for Physician Use179
Toward a Single Procedure Classification188
ICD-10-PCS -- A New Coding System191
9How We Code Today: Category Coding205
How "Category Coding" Works205
Walking Through: Coding "Polyneuropathy" with ICD-9-CM206
Examples from the Real World216
Section 3Problems & Solutions
Getting the Most from Our Health Information System223
10Preserving Truth in Medical Records225
The "System" Encourages Distortion of Information225
The Impact on Physician -- and Patient232
The "System" Should Back Off236
11Optimizing the Electronic Medical Record237
Getting the "Whole Truth"238
Designing the EMR to Improve Patient Care244
Increasing Security245
Standards for Health Information247
12Capturing the Clinical Detail257
We Aren't Getting Enough Information257
Introducing "Entity Codes"260
The Path to Coding261
13Entity Coding277
What Are Clinical Entities?277
Entity Codes279
How to Implement Entity Coding282
The Entity Coding Process286
Features of Entity Coding289
14Living Successfully with Code-Dependency291
Decoding Healthcare Codes291
The Missing Link in Our Medical Knowledge297
Making Meaning Precise303
Standards for Keys313
Markup Language May Hold the "Key"314
15Expanding Classification Possibilities317
Opening the Door for Multiple Classifications319
Entity Code Classifying320
The Joys of Entity Code Classifying324
16The Challenge of ICD-10329
Consequences of Change329
How to Buy Time334
17A New Beginning337
The Power of Codes337
Looking at Where We Are339
The "Wish List"340
Saving the Medical Record341
The Bottom Line343
Section 4Coding Systems
AInternational Classification of Diseases347
Introductions to ICD-6 & ICD-9364
BStandard Nomenclature of Diseases & Operations407
CDiagnosis Related Groups421
DUnified Medical Language System425
ESNOMED International429
FNHS Codes (Read Codes)459
GInternational Classification of Primary Care473
HIndex for Radiological Diagnoses483
Index for Radiological Diagnoses, Computer Version 4.1489
IMortality Medical Data System491
Section 5Other Resource Materials
KICD-9-CM Classification of the Circulatory System515
LNCVHS - 1993 Annual Report533
MCoding Resources551
About the Authors585

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