MODULE 2 - STRUCTURED TERMINOLOGIES

Our clinic uses CPT and ICD-9 codes for coding, we have the ICD codes on the computer and then also have a billing sheet where the level and ICD codes are documented. Many are not in the computer or on the sheet so we have a great billing person who will document for us when using correct medical terminology. We use structured medical and nuring terminologies for the most part, though we also use a lot of shorthand and abbreviations. The physicians actually use the most shorthand and abbreviations and the rest of the clinic adjusts and understands what is being said. Many of the codes and terminology are unknown to our lay front end and medical help. This sometimes will create a problem in the flow of the clinic.

The clinical data base is useful in promoting quality patient care by establishing benchmarks for immunizations and monitoring if are patients up-to-date. Monitoring if diabetics are getting their hemaglobin A1C done, along with eye checks, foot checks, etc. Since multiple providers see the same patient at different times, the codes provide evidence of promoting quality patient care and if not done, then using the information to establish this type of care.