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In health care, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification.
A clinical judgment about the healthcare consumer's response to actual or potential health conditions or needs. The diagnosis provides the basis for determination of a plan to achieve expected outcomes. Registered nurses utilize nursing and medical diagnoses depending upon education and clinical preparation and legal authority" [11]
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology, that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnosis.
An example of this is used by the International Statistical Classification of Diseases and Related Health Problems (known as ICD). ICD-10 groups diseases of the circulatory system into one "chapter", known as Chapter IX, covering codes I00–I99. One of the codes in this chapter (I47.1) has the code title Supraventricular tachycardia. However ...
Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations. First developed in 1994, it was created and is maintained by the Regenstrief Institute , a US nonprofit medical research organization.
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 ...
ICD-10-CM, for diagnosis codes, replaces volumes 1 and 2. Annual updates are provided. ICD-10-PCS, for procedure codes, replaces volume 3. Annual updates are provided. On 21 August 2008, the US Department of Health and Human Services (HHS) proposed new code sets to be used for reporting diagnoses and procedures on health care transactions ...