Standard Nomenclature

Roy H. Constantine  PA-C, MPH, PhD, FCCM, DFAAPA

Former CSPS Representative and Chair


Article originally printed in Sutureline: Jul/Aug 2015 pp. 12-13.

The Council on Surgical and Perioperative Safety (CSPS) endorses safe surgical resources with participation from all members of the multidisciplinary perioperative care team to achieve optimal patient outcomes.  This month the council is reinforcing the importance of standard nomenclature in the development of electronic medical records.

In healthcare, standard nomenclature is extremely important. This information may be required at point of care services or internationally. A common global language for health care terms has been developed by SNOMED CT.1

Striving for accurate and relevant information is paramount. Emphasis placed on improving cost, quality and efficiencies result from removing language barriers.3

Content can be broken down into further disease specific subsets. Classifications and coding can be cross-mapped with encoded data and can assist in reimbursement and statistical reporting. This broad coverage application allows for comprehensive, scalable, flexible and translatable terminology.4

The attempt to minimize error from other coding systems, classification and terminology can aid in minimizing duplication and cost.5

Validated content can be exchanged in multiple languages, within electronic health records, in data and data collection processes. This clinical information then becomes more relevant and allows for meaning-based retrieval.2  The accurate reflection of clinical documentation can be better supported. A good example of this can be found in standardized language documentation in the operating room known as “The Perioperative Nursing Data Set” where a data set with structured vocabulary is available. The integration of standardized terminology allows for consistent documentation and best practices in clinical care and research to occur.6

Another example can be found with the extraction and reporting of core measures, which is mandated by the Centers for Medicare and Medicaid (CMS) and other payers.7  

From a surgical perspective we will be heading towards the 10th revision of the International Classification of Diseases (ICD-10) as an international standard for the definition of medical conditions. This transition is a requirement under the Health Insurance Portability Accountability Act (HIPPA).8  It is highly recommended that you familiarize yourself with the Root Operating Groups in the Medical Surgical Related Section. It is the responsibility of the coders to input the correct root operation or procedure, but it is equally the responsibility of the clinician to document properly so that there is no variance with interpretation. Familiarizing oneself with these changes will result in better ICD-10 standard nomenclature preparation.

As surgical physician assistants we need to have a better understanding regarding the importance of standard nomenclature and the influence that ICD-10 will have on our clinical practice. Active participation in clinical documentation committees is imperative! The Surgical Physician Assistant is a key stakeholder in assuring that high degree of documentation standards are met. There is no excuse – WE ALL NEED TO BE INVOLVED!!!

References:

  1. SNOMED CT. Retrieved from http://www.ihtsdo.org/snomed-ct
  2. WHAT IS SNOMED CT.  Retrieved from http://www.ihtsdo.org/snomed-ct/what-is-snomed-ct
  3. WHY SNOMED CT. Retrieved from http://www.ihtsdo.org/snomed-ct/why-should=i-get-snomed-ct
  4. SNOMED CT WORLDWIDE – Retrieved from http://www.ihtsdo.org/snomed-ct/snomed-ct-worldwide
  5. SNOMED CT & OTHER TERMINOLOGIES. Retrieved from http://www.ihitsdo.org/snomed-ct/mapping-to-other-terminologies
  6. Sweeney, P. The Effects of Information Technology on Perioperative Nursing. AORN Journal, November 2010, 92(5): pgs. 528-540
  7. Schaefer, R.  Improve Core Measure Compliance with Electronic Medical Record Tools. ACP Hospitalist. 2012. Retrieved from http://www.acphospitalist.org/archives/2012/11/perspectives.htm?print=true
  8. ICD-10 Coding. American College of Surgeons. 2015. Retrieved from https://www.facs.org/advocacy/practmanagement/icd10