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

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Editorial Reviews

A pioneer in medical informatics, Slee warns that the impending nationwide conversion from one diagnosis coding system to another is merely another cliff in the plummeting quality of information in the medical industry. He details the forces that erode data quality and cause the loss of valuable clinical information, and poses solutions based on scientific principles, experience, and medical literature. He is joined by attorney and writer Debora Slee and attorney and informatics specialist H.J. Schmidt. Annotation c. Book News, Inc., Portland, OR (booknews.com)
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Product Details

  • ISBN-13: 9780961525521
  • Publisher: Tringa Press
  • Publication date: 1/1/1999
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 600

Table of Contents

List of Figures v
Foreword vii
Preface xi
Section 1 Overview
Abstract 2
1 Four Serious Flaws in Our Health Information System 3
Your Personal Medical Record 5
Code-Dependency in Health Information 8
The "Four Flaws"--Where the Problems Are 12
The Solutions: Living With "Code-Dependency" 26
The Time Challenge 34
A Great Opportunity 41
Section 2 History & Background
Medical Records, Coding, and Healthcare Classification 43
2 Primer on Medical Records 45
Formation & Contents 46
Uses of Medical Record Information 50
Health Information Professionals 53
The Electronic Medical Record (EMR) 60
3 Expression of Clinical Concepts 71
Types of Language 71
Uniformity in Clinical Language 77
Language Can't--and Shouldn't--Be Controlled 97
4 Retrieval of Medical Record Information 99
Access to Information 100
Hospital Discharge Abstract Systems 103
5 Codes & Coding 117
The Code: An Information "Identifier" 118
How Classifications Get Their Codes 121
Coding Processes 122
Maintaining Data Integrity 130
6 Classifications & Classifying 133
The Classification: An Information "Organizer" 134
Attributes of a Classification 135
Patient Information for Classifications 139
The Process of Classifying 144
7 Diagnosis Classifications 149
The Early Years Using SNDO 151
The International Classification of Diseases 155
The Tenth Revision of ICD 166
8 Procedure Classifications 175
History 175
Procedure Classifications for Hospital Use 176
Procedure Classifications for Physician Use 179
Toward a Single Procedure Classification 188
ICD-10-PCS -- A New Coding System 191
9 How We Code Today: Category Coding 205
How "Category Coding" Works 205
Walking Through: Coding "Polyneuropathy" with ICD-9-CM 206
Examples from the Real World 216
Section 3 Problems & Solutions
Getting the Most from Our Health Information System 223
10 Preserving Truth in Medical Records 225
The "System" Encourages Distortion of Information 225
The Impact on Physician -- and Patient 232
The "System" Should Back Off 236
11 Optimizing the Electronic Medical Record 237
Getting the "Whole Truth" 238
Designing the EMR to Improve Patient Care 244
Increasing Security 245
Standards for Health Information 247
12 Capturing the Clinical Detail 257
We Aren't Getting Enough Information 257
Introducing "Entity Codes" 260
The Path to Coding 261
13 Entity Coding 277
What Are Clinical Entities? 277
Entity Codes 279
How to Implement Entity Coding 282
The Entity Coding Process 286
Features of Entity Coding 289
14 Living Successfully with Code-Dependency 291
Decoding Healthcare Codes 291
The Missing Link in Our Medical Knowledge 297
Making Meaning Precise 303
Standards for Keys 313
Markup Language May Hold the "Key" 314
15 Expanding Classification Possibilities 317
Opening the Door for Multiple Classifications 319
Entity Code Classifying 320
The Joys of Entity Code Classifying 324
16 The Challenge of ICD-10 329
Consequences of Change 329
How to Buy Time 334
17 A New Beginning 337
The Power of Codes 337
Looking at Where We Are 339
The "Wish List" 340
Saving the Medical Record 341
The Bottom Line 343
Section 4 Coding Systems
A International Classification of Diseases 347
Introductions to ICD-6 & ICD-9 364
B Standard Nomenclature of Diseases & Operations 407
C Diagnosis Related Groups 421
D Unified Medical Language System 425
E SNOMED International 429
F NHS Codes (Read Codes) 459
G International Classification of Primary Care 473
H Index for Radiological Diagnoses 483
Index for Radiological Diagnoses, Computer Version 4.1 489
I Mortality Medical Data System 491
J Medcin 497
Section 5 Other Resource Materials
K ICD-9-CM Classification of the Circulatory System 515
L NCVHS - 1993 Annual Report 533
M Coding Resources 551
Bibliography 557
About the Authors 585
Colophon 589
Index 591
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