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LOINC
Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations. First developed in 1994, it was created and is maintained by the Regenstrief Institute, a US nonprofit medical research organization. LOINC was created in response to the demand for an electronic database for clinical care and management and is publicly available at no cost. It is endorsed by the American Clinical Laboratory Association. Since its inception, the database has expanded to include not just medical laboratory code names but also nursing diagnosis, nursing interventions, outcomes classification, and patient care data sets. Function ''LOINC'' applies universal code names and identifiers to medical terminology related to electronic health records. The purpose is to assist in the electronic exchange and gathering of clinical results (such as laboratory tests, clinical observations, outcomes management and research). LOINC has two m ...
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Integrating The Healthcare Enterprise
Integrating the Healthcare Enterprise (IHE) is a non-profit organization based in the US state of Illinois. It sponsors an initiative by the healthcare industry to improve the way computer systems share information. IHE was established in 1998 by a consortium of radiologists and information technology (IT) experts. Operations IHE created and operates a process through which interoperability of health care IT systems can be improved. The group gathers case requirements, identifies available standards, and develops technical guidelines which manufacturers can implement. IHE also stages "connectathons" and "interoperability showcases" in which vendors assemble to demonstrate the interoperability of their products. Sponsorship IHE is sponsored by the Healthcare Information and Management Systems Society (HIMSS), the Radiological Society of North America (RSNA), and the American College of Cardiology (ACC). The eye care domain is sponsored by the American Academy of Ophthalmolog ...
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SNOMED CT
SNOMED CT or SNOMED Clinical Terms is a systematically organized computer-processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting. SNOMED CT is considered to be the most comprehensive, multilingual clinical healthcare terminology in the world. The primary purpose of SNOMED CT is to encode the meanings that are used in health information and to support the effective clinical recording of data with the aim of improving patient care. SNOMED CT provides the core general terminology for electronic health records. SNOMED CT comprehensive coverage includes: clinical findings, symptoms, diagnoses, procedures, body structures, organisms and other etiologies, substances, pharmaceuticals, devices and specimens. SNOMED CT is maintained and distributed by SNOMED International, an international non-profit standards development organization, located in London, UK. SNOMED International is the trading name of the Intern ...
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PHQ-9
The 9-question Patient Health Questionnaire (PHQ-9) is a diagnostic tool introduced in 2001 to screen adult patients in a primary care setting for the presence and severity of depression. It rates depression based on the self-administered Patient Health Questionnaire (PHQ). The PHQ is part of Pfizer's larger suite of trademarked products, called the Primary Care Evaluation of Mental Disorders (PRIME-MD). The PHQ-9 takes less than 3 minutes to complete and simply scores each of the 9 DSM-IV criteria for depression based on the mood module from the original PRIME-MD. Primary care providers frequently use the PHQ-9 to screen for depression in patients. History The PHQ-9 is the 9-question depression scale of PHQ. The PHQ is a self-administered version of the PRIME-MD, a screening tool that assesses 12 mental and emotional health disorders. The PHQ is 59-question instrument. It has modules on mood (PHQ-9), anxiety, alcohol, eating, and somatoform disorders. Dr. Robert L. Spitzer, ...
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NPU Terminology
NPU terminology (NPU: Nomenclature for Properties and Units) is a patient centered clinical laboratory terminology for use in the clinical laboratory sciences. Its function is to enable results of clinical laboratory examinations to be used safely across technology, time and geography. To achieve this, the NPU terminology supplies: * Unique identifiers for types of examined properties of the patient, supporting structured communication and storage of laboratory data in e.g. clinical laboratory reports or electronic health records * Stable and unambiguous definitions of the types of examined properties, expressed using international nomenclatures, and in accordance with international standards * Specification of measurement units where relevant * A structure allowing for secure translation of the definitions into other languages Purpose The purpose of the NPU terminology is to enable patient examination data to be safely transmitted between laboratory information systems, recognize ...
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Medical Classification
A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot. Procedure classifications list procedure code, which are used to capture interventional data. These diagnosis and procedure codes are used by health care providers, government health programs, private health insurance companies, workers' compensation carriers, software developers, and others for a variety of applications in medicine, public health and medical informatics, including: * statistical analysis of diseases and therapeutic actions * reimbursement (e.g., to process claims in medical billing based on diagnosis-related groups) * knowledge-based and decision su ...
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Medical Laboratory
A medical laboratory or clinical laboratory is a laboratory where tests are conducted out on clinical specimens to obtain information about the health of a patient to aid in diagnosis, treatment, and prevention of disease. Clinical Medical laboratories are an example of applied science, as opposed to research laboratory, research laboratories that focus on basic science, such as found in some academia, academic institutions. Medical laboratories vary in size and complexity and so offer a variety of testing services. More comprehensive services can be found in acute-care hospitals and medical centers, where 70% of clinical decisions are based on laboratory testing. Doctors offices and clinics, as well as skilled nursing and Nursing home, long-term care facilities, may have laboratories that provide more basic testing services. Commercial medical laboratories operate as independent businesses and provide testing that is otherwise not provided in other settings due to low test vol ...
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Glasgow Coma Scale
The Glasgow Coma Scale (GCS) is a clinical scale used to reliably measure a person's level of consciousness after a brain injury. The GCS assesses a person based on their ability to perform eye movements, speak, and move their body. These three behaviours make up the three elements of the scale: eye, verbal, and motor. A person's GCS score can range from 3 (completely unresponsive) to 15 (responsive). This score is used to guide immediate medical care after a brain injury (such as a car accident) and also to monitor hospitalised patients and track their level of consciousness. Lower GCS scores are correlated with higher risk of death. However, the GCS score alone should not be used on its own to predict the outcome for an individual person with brain injury. Scoring The Glasgow Coma Scale is used for people above the age of two and composed of three tests: eye, verbal, and motor responses. The scores for each of these tests are indicated in the table below. The Glasgow Com ...
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Clinical Care Classification System
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings. The Clinical Care Classification (CCC), previously the Home Health Care Classification (HHCC), was originally created to document nursing care in home health and ambulatory care settings. Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care. The CCC was developed empirically through the examination of approximately 40,000 textual phrases representing nursing diagnoses/patient problems, and 72,000 phrases depicting patient care services and/or actions. The use of the CCC has expanded into other settings, and it is claimed to be appropriate for multidisciplinary documentation. The CCC, capturing the essence of patient c ...
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DICOM
Digital Imaging and Communications in Medicine (DICOM) is the standard for the communication and management of medical imaging information and related data. DICOM is most commonly used for storing and transmitting medical images enabling the integration of medical imaging devices such as scanners, servers, workstations, printers, network hardware, and picture archiving and communication systems (PACS) from multiple manufacturers. It has been widely adopted by hospitals and is making inroads into smaller applications such as dentists' and doctors' offices. DICOM files can be exchanged between two entities that are capable of receiving image and patient data in DICOM format. The different devices come with DICOM Conformance Statements which state which DICOM classes they support. The standard includes a file format definition and a network communications protocol that uses TCP/IP to communicate between systems. The National Electrical Manufacturers Association (NEMA) holds the cop ...
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Clinical Data Interchange Standards Consortium
The Clinical Data Interchange Standards Consortium (CDISC) is a standards developing organization (SDO) dealing with medical research data linked with healthcare, to "enable information system interoperability to improve medical research and related areas of healthcare". The standards support medical research from protocol through analysis and reporting of results and have been shown to decrease resources needed by 60% overall and 70–90% in the start-up stages when they are implemented at the beginning of the research process. CDISC standards are harmonized through a model that is also a HL7 standard and is the process to becoming an ISO/ CEN standard. History * Late 1997 – Started as a Volunteer group * Summer 1998 – Invited to form DIA SIAC * 1999 – SDS v1.0; ODM v0.8 * 2000 – SDS v1.1 * Feb 2000 – Formed an Independent, non-profit organization * Dec 2001 – Global participation * 2001 – SDS v2.0; ODM v1.0 * 2002 – ODM v1.1; ADaM v1.0 * 2003 – LAB v1.0; SDTM ...
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UMLS
The Unified Medical Language System (UMLS) is a compendium of many controlled vocabularies in the biomedical sciences (created 1986). It provides a mapping structure among these vocabularies and thus allows one to translate among the various terminology systems; it may also be viewed as a comprehensive thesaurus and ontology of biomedical concepts. UMLS further provides facilities for natural language processing. It is intended to be used mainly by developers of systems in medical informatics. UMLS consists of Knowledge Sources (databases) and a set of software tools. The UMLS was designed and is maintained by the US National Library of Medicine, is updated quarterly and may be used for free. The project was initiated in 1986 by Donald A.B. Lindberg, M.D., then Director of the Library of Medicine, and directed by Betsy Humphreys. Purpose and applications The number of biomedical resources available to researchers is enormous. Often this is a problem due to the large volume of ...
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DOCLE
DOCLE (Doctor Command Language), is a non-numeric health coding and medical classification system. The DOCLE system is used in Health Communication Network's electronic medical record and patient management software package, Medical Director. Medical Director is the most widely used electronic medical record system by Australian primary health care providers. DOCLE has been modelled on the Linnaean biological classification system since 1995. DOCLE generates clinical codes from ubiquitous health language using an algorithm, hence it is a human readable clinical coding system. The design principles of DOCLE, as enumerated by the author in the DOCLE website include: * DOCLE codes being meaningful and intentional * DOCLE codes are derived from ubiquitous health language * DOCLE codes grew with evolving order and speciation of large scale structures in a linnean manner. * DOCLE codes are designed to strap together and form clinical structures using joiner codes * The author of DOCLE, ...
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