How Do I Learn Medical Coding?

Medical information standards refer to the standards widely used in medical information and standards for medical applications, and professional technical standards for medical applications.

Medical Information Standard

This entry lacks an overview map . Supplementing related content makes the entry more complete and can be upgraded quickly. Come on!

Medical information standards refer to the standards widely used in medical information and standards for medical applications, and professional technical standards for medical applications.

Chinese name

Medical Information Standard

Concept

Medical professional technical standards

Standards organization

Current Procedural Terminology

DICOM standard

Compensation fees to hospital based on decision

Standards widely used in medical information and standards for medical applications, professional technical standards for medical applications, such as the communication protocol standards UDP, TCP / IP, FTP, etc. used for communication, and storage standards Standards such as JPEG, TIFF, PICF, FAX, Media, etc. will be given a brief description when they are involved, but they are not listed in the table below, because such standards do not require the hospital's IT staff to understand It is widely used in various aspects, and its medical application standards cannot be better applied and developed if the hospital staff and medical informatics researchers do not understand it. Nor can it learn from the successful or failed standardization. The experience is based on the alphabetical order of each standard. If there is a detailed text after each standard, it means that you can click on the relevant link for a detailed introduction. If you provide a related website address or only a brief introduction, it means that there is no more information. , You are welcome to provide more relevant information. Ironstone is responsible for sorting and maintenance. If you have any related questions, please contact it. Before understanding these standard systems and coding systems, you should note that all classification coding systems have disadvantages, and no coding system can meet the needs of all users. Therefore, after understanding these standards, it is very important to understand the scope of application, purpose and population of these standards.

ATC (Anatomical Therapeutic Chemical) Anatomical-therapeutic-chemical code; is a hierarchical classification of drug systems. In the early 1870s, the Norwegian Medical Supply Division expanded the existing European Pharmaceutical Market Research Association Anatomical and Therapeutic Class 3 classification system and added 2 chemical classes. Later, the ATC classification was approved by the WHO Drug Application Research Group and maintained by the WHO Collaborating Centre for Drug Statistics Methodology in Oslo. The advantages of ATC are as follows: (1) A drug product is identified, including effective substances, routes of administration and related doses. (2) Both treatment-oriented and chemical-oriented, this feature is lacking in other systems. (3) Its hierarchical structure allows logical grouping. (4) It has been used as the international standard for WHO drug research. The disadvantage is that it does not contain compound products, dermatological preparations and topical compound preparations. CPT (Current Procedural Terminology, United States) Common process terminology; is a set of coding systems used in the US payment compensation coding system, which defines the diagnosis and treatment process based on consumption and provides coding strategies. It is a classification code and terminology system used by hospitals for clinical operations and service delivery. It is widely used in payment and application evaluation in the United States. Published annually by the American Medical Association (AMA). (CPT4 is often seen on some foreign DEMO forums, referring to the fourth version of CPT: Current Procedural Terminology, 4th Edition)

(Digital Imaging and Communication in Medicine)-Discussion columns in this forum: Medical imaging technology, Pacs system, DICOM3 standards, DRG (Diagnosis Related Groups, US) Chinese name: diagnostic related group; developed by the US HCFA (Health Care Financing Administration) Is a classification coding standard used in the US medical insurance advance payment system. The code divides patients into about 500 diagnosis-related ones based on the patient's age, gender, length of stay, clinical diagnosis, illness, surgery, disease severity, and outcome, etc., and uses this as a basis to determine the compensation costs to the hospital. The diagnosis is based on the ICD-9-CM code. The code was introduced and modified by many countries. DRGs lack clinical specificity in direct patient care or clinical research. China has also conducted research on DRGs. DRGs can also be used in budgets, but their use remains controversial. DSM (Diagnostic and Statistical Manual of Mental Disorders) Coding System for Diagnostic and Statistical Manual of Mental Disorders; a special code designed, developed, and maintained by the American Psychiatric Association (APA). The first edition was published in 1952. The current version is the fourth edition (DSM-IV), which proposes a series of code standards for use in diagnostics, prescriptions, research, education, and management. The ICD 10 code (The International Statistical Classification of Diseases and Related Health Problems, tenth revision, WHO) was developed by the World Health Organization (WHO) based on early European standards. The ICD code was originally used for disease rates and mortality. registration. The first edition was published in 1900 and was revised approximately every ten years. After the sixth edition, it gradually expanded to the applications of classification, retrieval and statistics for clinical diagnosis and surgical operation in hospitals. Based on this, a number of other versions and standards have been derived, such as: ICD-9-CM is a clinically revised version of ICD-9 in the United States and is the basis of the American DRG. The tenth edition was published in 1992. This edition has undergone many extensions and modifications, and has begun to meet the needs of epidemiological and health assessments. China has begun to apply ICD-10 code on the first page of medical records on January 1, 2001.

ICPC (International Classification of Primary Care). Basic medical and health issues involve biological, psychological, and social issues, which are often difficult to cover with the ICD classification system. General practitioners / family doctors, national colleges, universities, and societies The World Organization of National Colleges, Academies and Academic Associations of General Practitioners / Family Physicians (abbreviation: WONCA; also known as: World Organization of Family Doctors) did not accept the ICD code, but established its own Classification, this system is more detailed than ICD-9, not only contains the diagnostic code, but also contains the reason for the visit, the reason for treatment and the test results. ICPC can structure patient visit codes based on SOAP guidelines. This code is maintained by WONCA INTERNATIONAL CLASSIFICATION COMMITTEE (WICC) under WONCA. The diagnosis is classified according to two axes, one axis is the organ system (represented in characters), and the other axis is the medical component (represented in numbers, see table 6.1 below). Source: "Medical Informatics" book. Table 6.1 The first axis of the biaxial system of ICPC: Organ system code Organ system A Universal and unspecified B Blood D Digestion F Eye H Ear K Circulation L Muscle-Bone N Nerve P Psychology R Breath S Skin T Endocrine and Metabolism U Urinary W Pregnancy and Family Planning X Female Reproductive System Y Male Reproductive System Z Social Issues Second Axis: Medical Component Code Medical Component 1-29 Symptoms and Complaints 30-49 Diagnostic Screening and Prevention 50-59 Treatments and Drugs Processing 61-61 test results 62 Management 63-69 Other 70-99 diagnosis Supplementary note: At present, WICC is developing the ICPC2 code. The coding system and ICD-10 have a certain correspondence with ICPM () International Medical Process Code; mainly in Germany and Dutch application. ICIDH (International Classification of Impairments, Disabilities and Handicaps) International Classification of Impairments, Disabilities and Disabilities; IS & C (Image Save and Carry, Japan)

(Health Level 7, United States)-Discussion forum of this forum: HL7 Forum; detailed HIPAA (Health Insurance Portability and Accountability Act / 1996, Public Law 104-191, United States) Detailed HIPAA is not a standard itself, but because of HIPAA, Promoted the development of many related information standards, and set these standards as the requirements of the bill. I have an understanding of this and can better learn some foreign experiences, so here are the introductions. LOINC (Logical Observation Identifiers Names and Codes, United States) This system is a special group of clinical pathologists, chemists, and laboratory service developers the Community of Scholars of the Regenstrief Institute for Health Care at the Hartford Foundation, It was developed with the support of the National Medical Library (NLM) and the American Medical Regulatory Research Agency (AHCPR). The goal of this project is to produce a common inspection code system for correlation of laboratory results and observations in ASTM E1238 and HL7 version 2.2. The LOINC database includes records of laboratory observations of chemistry, toxicology, serology, microbiology, and some clinical variables. The database currently contains approximately 32,000 observation terms, of which 20,000 are related to laboratory tests. LONIC has been recognized by other standard systems and has been synthesized into UMLS. LONIC can be downloaded from the Internet and used for free. Special note: I do nt know why I used Logical instead of Laboratory. From its content, it should be about the Laboratory Observation Identifiers Names and Codes --- Laboratory observation result identifier names and code systems. My information is wrong, but LOINC's homepage writes Logical. How can I never make such a joke? :) Then I found the place where LOINC was mentioned in HL7, which is also Logical. The name should be correct, but why use the word? Still don't quite understand. If you have a clear netizen, please advise! MeSH (Medical Subject Headings) Medical Subject Thesaurus; developed and maintained by the US National Library of Medicine (NLM). Index to world medical literature. MeSH forms the basis of UMLS. NANDA code (North American Nursing Diagnosis Association, North America)

NDC (National Drug Code, United States) United States drug code; this code system is maintained by the United States FDA, mainly used for medical insurance, Medicaid and insurance company payments. The UPC (Universal Product Code) format sometimes contains an NDC code. RCC (Read Clinical Code, UK) The Read code, also known as the Read clinical classification, was personally developed by James Read, a British general practitioner, in the early 1980s. Adopted by the National Health Service (NHS) in 1990. And further expansion of RCC in clinical term engineering. RCC is specially developed for the electronic medical record system, the purpose is to cover all the terms that may be used in the medical record, covering all areas of the medical and health field. RCC uses a five-digit alphanumeric code. More than 650 million codes are theoretically allowed. RCC is compatible and cross-referenced with all other widely used standard classifications, such as: ICD-9, ICD-9-CM, DRGs, CPT-4, OPCS-4, etc. RCC has all terms in these classification systems One-to-one correspondence or correspondence. Clinical Terminology Engineering is implemented by a working group led by the NHS CEO, including representatives of the Royal College of Medicine, the Joint Advisory Board, the General Medical Services Committee of the British Medical Association and the NHS Executive Officer. SCP-ECG (Standard Communication Protocol) Transmission standard for ECG

SNOMED (The Systematized Nomenclature of Medicine, United States) was previously called: Systematized Nomenclature of Human and Veterinary, Systematized Nomenclature of Human and Veterinary Medicine. In 1933, the New York Medical College began research on a medical terminology database, the so-called Standard Classified Nomenclature of Diseases. The American Medical Association continued this work in 1961 and published the Systematic Nomenclature of Pathology (SNOP) coding system by the American College of Pathologists in 1965. SNOP has laid the foundation of the Systematic Nomenclature of Human and Veterinary Medicine (SNOMED), and has become an example of a special term set. SONMED was released in 1975. The latest version is called: SNOMED International; UMLS (Unified Medical Language System, United States).