Abstract:
Computer-based patient data which are represented in a coded form have a variety of
uses, including direct patient care, statistical reporting, automated decision support,
and clinical research. No standard exists which supports all of these functions. Abstracting
coding systems, such as ICD, CPT, DRGs and MeSH fail to provide adequate detail, forcing
application developers to create their own coding schemes for systems. Some of these
schemes have been put forward as possible standards, but they have not been widely
accepted. This paper reviews existing schemes used for abstracting, electronic record
systems, and comprehensive coding. It also discusses the remaining impediments to
acceptance of standards and the current efforts to overcome them, including SNOMED,
the Gabrieli Medical Nomenclature, the Read Clinical Codes, GALEN, and the Unified
Medical Language System (UMLS).
Keywords:
Controlled Medical Vocabulary - Nomenclature - Taxonomy - Electronic Medical Records
- Medical Record Coding - Review