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Vocabulary standards

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Definition Edit

Vocabulary standards

establish common definitions for medical terms and determine how information will be represented in medical records. These standards are intended to lead to consistent descriptions of a patient's medical condition by all practitioners.[1]

Overview Edit

"The use of different terms and codes (abbreviated representations of medical terms) to indicate the same condition or treatment complicates retrieval and reduces data reliability and consistency. The development of vocabulary standards is a formidable task because of the complexity of medical terminology, the unresolved issues such as the extent to which coding will be required, and the difficulty of choosing a single set of codes from the many that are available."[2]

References Edit

  1. Automated Medical Records: Leadership Needed to Expedite Standards Development, at 8.
  2. Id. at 9.

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