Changes in Medical Documentation over the Last Five Decades.
In medical documentation, standardized coding schemes are used to facilitate sharing, transformation and reusability of data. First, classification systems coding schemes have been introduced. While classification systems are mainly used for statistical purposes, individual care documentation moves towards the use of nomenclatures coding schemes. The paper presents an overview of the development of coding schemes. Different coding schemes serve different purposes. Multiaxial schemes are the way of choice for comprehensively documenting complex care processes. There is a movement from mono-hierarchical classification systems to concept-based, multi-purpose and multi-hierarchical terminologies.
Dudeck
Joachim
J
Institute of Medical Informatics, University of Giessen, Germany. Joachim.W.Dudeck@informatik.med.uni-giessen.de
D039702:Current Procedural Terminology / Q000266:history; D049673:History, 20th Century; D049674:History, 21st Century; D006801:Humans; D019451:Information Management / Q000266:history / Q000639:trends; D038801:International Classification of Diseases / Q000266:history; D016347:Medical Records Systems, Computerized / Q000266:history* / Q000639:trends; D008501:Medical Records, Problem-Oriented; D018875:Vocabulary, Controlled / Q000266:history