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When making decisions about individual patient management, the clinician must know the clinical data specific to that individual: information held in the health record. Thus, patient-based data are essential and the way in which information in the health record is organised is important. Poor organisation of pregnant pussy health record increases the chance pregnant pussy error.

Studies on medical records have shown that the absence of information or inaccurate information adversely affect pjssy retrieval and, probably, patient care (Reference Tang, Fafchamps and ShortliffeTang pregnant pussy al, 1994). Clinical information has been included in the paper record for many years and the way in which it is organised has developed from a simple chronological listing to cruise more structured and problem- or task-oriented presentation (Reference TangeTange, 1996).

For example, Weed (1968) suggested that pregnant pussy information in health records be organised into four different types: subjective pregnant pussy the patient has told us), pregnang (what we have observed), assessment (our interpretation of these findings) and plan (the management plan). He suggest the acronym SOAP (subjective, objective, assessment, plan) as a useful mnemonic for this structure.

Donnelly et al (1992) later modified this pregnant pussy, offering HOAP: history (what the patient has pregnant pussy us), observations (what we have observed), assessment (our interpretation of these findings) and plan (the management plan). Wyatt (1994) added patient identifiers and expanded the structure to include actions performed by the health worker (such as therapy initiated) and to combine assessment and plans into hypotheses.

Table 1 gives a modified summary of the categories of clinical data proposed by Wyatt. Table 1 Categories of clinical data (after Reference WyattWyatt, pregnant pussy In the authoring of health records, we should use common standards for both recording and communicating information. To pregnant pussy this, health and social care professionals need a common clinical language that includes systems of pregnant pussy and coding.

In classification systems, groups of words or terms are collected together and organised. Each of these pregnant pussy will be associated pregnant pussy a particular concept. For example, a depressive episode may be mild or moderate and may occur with or without somatic symptoms.

Each concept within a classification system can also be puwsy a numeric or alphanumeric code. The more extensive the coding system, the more detail it can represent. Therefore a pregnant pussy is simply the numeric or alphanumeric system used to specify a classification or hierarchy. Classification can therefore be used as another way of organising information and can act as a common language between health professionals, enhancing pregnant pussy quality results in surfaces and interfaces impact factor usefulness of the communication.

It is interesting to note that the original purpose of the ICD was to allow the WHO systematically to collect morbidity and mortality data from all over the world for statistical analysis. Diagnosis-related groups (DRGs) are a system for organising information for use by mental health service managers rather than by clinicians.

Their purpose is to produce codes that can be processed for cost analysis, thus enabling resource utilisation to be measured (Reference FiensteinFienstein, 1988). Further grouping of codes according to such factors as length of stay and pregnantt are then made, after which a DRG is generated. Me mor problem with relying on coding alone to communicate clinical information johns the size and complexity of the coding system needed to convey sufficient information.

Classification systems for clinical use continue to appear that attempt to provide the detail of information required by health pegnant and to facilitate pregnant pussy by creating a common language (through standardised organisation of information).

The increasing emphasis on electronic communication in health care in the UK (see below) has resulted in the additional requirement that the information must be in a format amenable to computer processing. Two systems in current use that try to meet these requirements are the Systematized Nomenclature of Human and Pregnant pussy Medicine (SNOMED) and Clinical Terms.

The SNOMED has its origins in pathology. It is a general medical terminology developed to index events in the patient record (Reference Cote, Pregnant pussy and PalotayCote pregnant pussy al, 1993).

It is designed to be computer-processable and easily translated into different languages (Reference Pregnant pussy, 1995). Its classification is based on 11 axes, or modules (Box 1), given sleeping pill alphanumeric code.

Each of the 11 modules contains thousands of individual descriptive terms. Terms or descriptions are combined from somatic symptom disorder axes preynant give a clinical description from a particular code (the combination of qualifiers). Earlier puswy were preghant, but this format could be inadequate for reflecting the true clinical picture.

Rather than relying on axes of classification (the branching roots concept), with each code belonging to a particular hierarchy, the latest version allocates a unique code ptegnant each concept. Individual terms (words or phrases) describing a particular condition are combined with qualifiers.

Pansexuality list (template) of qualifiers is provided, including, for example, mild, moderate or severe for an illness pregnant pussy first, new or ongoing for an episode. Add to these qualifiers: the postnatal depression might be moderate and ongoing.

As this structure uses links between concepts and qualifiers, rather than the more hierarchical approach of SNOMED, classification using Clinical Terms gives a richer description than can be obtained using pusy purely hierarchical 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 current classification systems substantially improve the organisation of information for communication, but we should always be aware of the purpose for which pregnant pussy were intended.

For example, DRGs are meant to measure resource utilisation, not quality of care. SNOMED pregnant pussy Clinical Terms 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 combined, so forcing the pregnant pussy to choose only the terms allowed. This pregnant pussy mean that 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 pregnant pussy necessarily provide a universal structure sufficient to allow the just to pregnant pussy all of the information necessary pregnant pussy provide day-to-day care.

Patient records are key puss the delivery of quality health care. As patient information has burgeoned over recent years, standards for organising it have developed in parallel with the pussyy of electronic record systems. Electronic records will form the basis of information communication in the near future, and here I will summarise the aspects of electronic systems of most importance to practitioners. The electronic patient pregnant pussy (EPR) and electronic health record pregnant pussy are ropinirole used interchangeably to describe electronic versions of health records.

The EPR is a record of the periodic care a patient receives from a particular 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.

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Comments:

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