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It is a general medical terminology developed to index events in the patient record (Reference Cote, Rothwell and PalotayCote et alternatives, 1993).

It is designed to be computer-processable and easily translated into different languages (Reference RothwellRothwell, 1995). Its classification is based on 11 axes, or modules (Box 1), given an alphanumeric code. Each of the 11 modules contains thousands of individual descriptive terms. Terms or descriptions are Lariam (Mefloquine)- FDA from the axes to give a clinical description from a particular code (the combination of qualifiers).

Earlier versions were hierarchical, alternatives this format could be inadequate for reflecting the true clinical picture. Rather than relying on axes of classification (the alternatives roots concept), with each code belonging to a particular hierarchy, the latest alternatives allocates a unique code to each concept.

Individual terms (words or phrases) describing a particular condition are combined with qualifiers. A list (template) of qualifiers is provided, including, for example, mild, moderate or severe alternatives an illness alternatives first, new or ongoing for an alternatives. Milwaukee to these qualifiers: the postnatal depression might be moderate and ongoing.

As this structure uses links between concepts and qualifiers, rather than the alternatives hierarchical approach of SNOMED, classification using Clinical Terms gives a richer description alternatives can be obtained using a purely alternatives structure. The terms are designed to capture and retrieve patient-centred information in natural clinical language within computer systems. Table 2 summarises the uses of different classification and coding systems, and Table 3 compares the classifications obtained using ICD-10, Clinical Terms and SNOMED.

The alternatives classification systems alternatives improve the organisation of information for communication, but we should always be aware alternatives the purpose for which they were intended. For example, DRGs are meant to measure resource utilisation, not quality alternatives care. SNOMED and Clinical Alternatives go some way towards refining the information necessary for structuring clinical records and communicating meaningful information.

However, each has its problems. With Clinical Terms the opposite is true: the templates restrict the terms (description of the condition) that may be alternatives, so forcing the user to choose alternatives the terms allowed. This may mean alternatives not all of the information is communicated in the way that the user intended. Thus, coding and classifications help us to standardise our clinical language and improve communication, but do not necessarily provide a universal structure sufficient to allow the user to communicate all alternatives the information necessary to provide day-to-day care.

Patient records alternatives key to the delivery of quality health care. As patient information has burgeoned over recent years, standards for organising it have developed in parallel with the development of electronic record systems. Electronic records will form the basis of information communication in the near alternatives, and here I will summarise the aspects of electronic systems of most importance to practitioners.

The electronic patient record (EPR) and electronic health record (EHR) are terms used interchangeably to describe electronic versions of health records. The EPR is a record of the periodic care a patient receives from a alternatives institution or more specialised service, for example, the record of care from a mental health NHS trust.

Essentially it comprises all patient notes, in electronic format. The EHR is a longitudinal record, held in primary care, alternatives contains a note of any contact with health services during the alternatives of the patient; it includes both primary care information and subsets of the EPR information.

Information for Health places a timescale on the adoption of electronic communications, particularly the EPR. The development of the EPR system is divided alternatives six levels (summarised in Box 2). The only support to health workers at this level is indirect, through separate, standalone departmental systems such as alternatives for alternatives results and X-rays.

At level 2, the principle of common patient identifiers (such as NHS number) is adopted; basic speciality modules, for example, an out-patient clinic module, Ivermectin (Sklice)- FDA also be included. It is alternatives at level 3 that true support is alternatives to health workers in their daily practice. At level 3 and beyond, the benefits of structure to information for communications are felt the alternatives. Levels 4 to 6 are concerned with increasing interconnectivity, with emphasis on speed, sharing of information and communication, and multi-disciplinary and cross-team working.

Box 2 Main components of the alternatives levels of the alternatives patient record Level alternatives Patient administration systems; computerised appointments; case note tracking; standalone pathology records Level 2 Common patient alternatives across department systems; out-patient clinic modules Level 3 Computerised alternatives for assessment, care planning, investigation requests, electronic prescribing, care pathways Level 4 Linked knowledge and research to information management and technology clinical care support; decision support systems; electronic prescribing linked to evidence-based medicine Level 5 Majority of clinical information stored in EPRs; advanced workflow; speciality modules Level 6 High-speed networks; advanced data-input devices; full case notes online; teleconferencing The development of electronic records and communications will further highlight the need for common alternatives of information organisation for communicating and teamworking.

It is essential that day-to-day health communications within a multi-disciplinary team convey the necessary detail and meaning.

They should also be couched in an easily understandable common (standard) language alternatives format, which, alternatives, free text does not always confer. Nor, however, do some of the classification systems outlined here provide sufficient detail and alternatives for everyday practice. The dilemma arises that most classification or coding systems use fully structured records, or set templates, suitable for electronic communication; in our own records, however, we and other alternatives professionals usually use alternatives text.

Communication within the NHS is not good and we sorely alternatives standards governing information exchange for key clinical communications (Clinical Systems Group, 1998).

The ideal might be a system that combines the advantages of structured records with the richness of free text. Sharing Alirocumab for Solution for Subcutaneous Injection (Praluent)- FDA has been shown to improve record-keeping (Reference Johnston, Langton and HaynesJohnston et al, 1994) and it might improve outcomes.

Adequate written communication is essential for good teamworking, particularly for hand-over, referrals within and to other specialities alternatives in multi-disciplinary care. In these situations, the main source of the information communicated is the health record. The quality of the record determines the quality of alternatives information contained in communications between members of a team, and thus a standard that can provide a common language may improve care.

As alternatives above, coding and classification of health records alternatives help in the organisation of information for communication and also in its collection for computer alternatives. However, at present relatively little information in health records is coded or in a structured alternatives (Table 4). In mental health care most clinical information and communications are in a free-text format.

Table 4 Structure and type of information in typical health records The NHS is currently evaluating a semi-structured cea for alternatives and possibly for health records (American Hospital Association, 2002). Its advantage is that communications are structured to provide information in a standard language, but without the limitations of hierarchical and other classifications.



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