EVALUATION OF CODING AND ITS RELATIONSHIP WITH STANDARDIZED CLINICAL TERMINOLOGIES

Accurate coding of healthcare diagnoses and surgical procedures has become progressively more critical as healthcare data needs have advanced. The use of structured data in coded form continues to increase as the healthcare industry seeks overall improvement in the quality of care render to patients. The use of standardized terminology to describe clinical progress and treatment procedures is a means for ensuring that all the health professionals in the healthcare setting involved in patient care have a common understanding of the patient’s illness. The differences in the terminology and system used for coding obstruct the identification of uniform and best practices for representing and communicating medical information. Great progress has been made in the development of standardized sets of health care terms, yet experts agree that gaps and areas of overlap are present in existing standardized terminology and that no single terminology can meet all needs as some illnesses have one clearly superior path and patient preferences may play very little or no role in decision making while for many medical decisions multiple path exist that entail different combinations of treatment options and outcomes.