Clinical Terminology in Patient Health Record System - SNOMED CT Overview

Novita Dewi , Ika and Khanapi Abd Ghani , Mohd (2013) Clinical Terminology in Patient Health Record System - SNOMED CT Overview. FIKI 2013, 1 (1). ISSN 979-26-0263-1

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Abstract

Background of study: Patient Health Record System (PHRS) is used by physicians for capturing patient medical records in electronic media. Standardization in PHRS arises a major challenge due to its complexities. The used of clinical terminology is needed in order to facilitate more expressive clinical data input, provide unambiguous encoding and support the exchange of clinical information. One of highly specialized clinical terminology is SNOMED CT(Systematized Nomenclature of Medicine Clinical Terms) that able to encode clinical data, and contains concepts that linked to clinical knowledge to enable accurate recording of data without ambiguity. The aims of this paper is to discuss the use of clinical terminology in PHRS and identifying importance factors for applying clinical terminology in healthcare services. Method: This study used review of literature in order to find the use of clinical terminology in patient health record system by reviewing current used of clinical terminology. Result: The result of the study found that clinical terminology supports information exchange between healthcare providers

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