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Clinical Coder. A clinical coder —also known as clinical coding officer, diagnostic coder, medical coder, or nosologist —is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system. The health data produced are an integral part of health information ...
It is used for alert (conscious) people, but often much of this information can also be obtained from the family or friend of an unresponsive person. In the case of severe trauma, this portion of the assessment is less important. A derivative of SAMPLE history is AMPLE history which places a greater emphasis on a person's medical history. [2]
SNOMED started in 1965 as a Systematized Nomenclature of Pathology (SNOP) and was further developed into a logic-based health care terminology. [6] [7]SNOMED CT was created in 1999 by the merger, expansion and restructuring of two large-scale terminologies: SNOMED Reference Terminology (SNOMED RT), developed by the College of American Pathologists (CAP); and the Clinical Terms Version 3 (CTV3 ...
Informed refusal. Informed refusal is where a person has refused a recommended medical treatment based upon an understanding of the facts and implications of not following the treatment. [1][2] Informed refusal is linked to the informed consent process, as a patient has a right to consent, but also may choose to refuse. [3]
Examples of areas to reduce medication errors and improve safety include: Training professionals or using databases to compare new and previous prescribed medications to prevent mistakes, also known as "medication reconciliation", [145] prescribing through an electronic medical record system and/or using decision support systems that has ...
Medical transcription. Medical transcription, also known as MT, is an allied health profession dealing with the process of transcribing voice-recorded medical reports that are dictated by physicians, nurses and other healthcare practitioners. Medical reports can be voice files, notes taken during a lecture, or other spoken material.
The false positive rate (FPR) is the proportion of all negatives that still yield positive test outcomes, i.e., the conditional probability of a positive test result given an event that was not present. [6] The false positive rate depends on the significance level. The specificity of the test is equal to 1 minus the false positive rate.
The Current Procedural Terminology (CPT) code set is a procedural code set developed by the American Medical Association (AMA). It is maintained by the CPT Editorial Panel. [1] The CPT code set describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among ...
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