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Medical Records Briefing Strategies for Health Care Compliance

As more healthcare providers transition from paper records to an electronic record, health information exchanges are the next logical step.

Optimize the benefits of these technological advances by increasing your EHR vocabulary. The following terms are recommended for use in health information exchange:

• SNOMED CT (Clinical Terms) is a comprehensive clinical reference terminology that allows for consistent capture of detailed clinical information. It was developed by the College of American Pathologists (CAP) and is maintained by SNOMED International, a division of CAP, which has licensed its use to the National Library of Medicine for making the core content available free of charge.
• LOINC, Logical Observation Identifiers Names and Codes, is a system developed by the Regenstrief Institute and funded by the National Library of Medicine, the Hartford Foundation, and other HHS funding sources, to capture laboratory and other observational data.
• RxNorm, which normalized notations for clinical drugs, is a system developed by the National Library of Medicine, Veterans Administration, and Food and Drug Administration to standardize notation of clinical drugs.
• UMDNS, Universal Medical Device Nomenclature System, is a standard international nomenclature and computer coding system for medical devices. UMDNS is used to facilitate the identification, processing, filing, storage, retrieval, transfer, and communication of data about medical devices. The nomenclature is used in applications ranging from hospital inventory and work-order controls to national agency medical device regulatory systems and from e-commerce and procurement to medical device databases.

This tip is from The No-Hassle Guide to EHR Implementation published by HCPro, Inc.