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LOINC applies universal code names and identifiers to medical terminology related to electronic health records. The purpose is to assist in the electronic exchange and gathering of clinical results (such as laboratory tests, clinical observations, outcomes management and research). LOINC has two main parts: laboratory LOINC and clinical LOINC.
NPU terminology (NPU; Nomenclature for Properties and Units) is a patient centered clinical laboratory terminology for use in the clinical laboratory sciences. Its function is to enable results of clinical laboratory examinations to be used safely across technology, time and geography. To achieve this, the NPU terminology supplies:
The Systematized Nomenclature of Medicine (SNOMED) is a systematic, computer-processable collection of medical terms, in human and veterinary medicine, to provide codes, terms, synonyms and definitions which cover anatomy, diseases, findings, procedures, microorganisms, substances, etc. It allows a consistent way to index, store, retrieve, and ...
Handwritten paper medical records may be poorly legible, which can contribute to medical errors. [14] Pre-printed forms, standardization of abbreviations and standards for penmanship were encouraged to improve the reliability of paper medical records. An example of possible medical errors is the administration of medication.
A medical test is a medical procedure performed to detect, diagnose, or monitor diseases, disease processes, susceptibility, or to determine a course of treatment. The tests are classified by speciality field, conveying in which ward of a hospital or by which specialist doctor these tests are usually performed.
NABL being a governmental body conducts integrated assessments with regulators such as FSSAI, EIC, APEDA, etc. Integrated assessments simplify the process of recognition, as the laboratory can get accredited and recognized by the regulator in one combined assessment instead of the separate multiple assessments which are usually needed.
CDA can hold any kind of clinical information that would be included in a patient's medical record; examples include: [1] Discharge summary (following inpatient care) History & physical; Specialist reports, such as those for medical imaging or pathology
The medical record serves as the central repository for planning patient care and documenting communication among patient and health care provider and professionals contributing to the patient's care. An increasing purpose of the medical record is to ensure documentation of compliance with institutional, professional or governmental regulation.
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