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Questions1

Currentprocedural terminology (CPT) is one of the nomenclatures used inmedical procedures. Briefly describe its application in the medicalhealth.

Question2

Brieflydescribe clinical care classification taxonomy

Answers

Question1

CurrentProcedure Terminology is a nomenclature used to code procedures anddiagnosis offender by medical professional in a health facility. Thisincludes medical, surgical and psychiatric services. It is a uniformsystem that is used by medical professions to streamlinecommunication and medical reporting. This increases accuracy andefficiency of health services. This is by ensuring that the use of auniform language in describing medical services in order tofacilitate bailing and documentation. According to HIPAA guidelines,all medical service providers as well as payers in the United Statesare required to use this nomenclature in recording and documentationof procedures for all proposes. For example, the Center for Medicaidand Medicare values are based on Current Procedure Terminology(Michelle, 2010).

Question2

TheClinical Care Classification is a national standard mainly used innursing in the documentation of patient information and medical careplans in the electronic health record. The system providesstandardized and coded health care terminologies that supportelectronic health record inputs. It is applicable in the normaldiagnosis process as well as emergency cases. Therefore, it can beused in home based nursing care as well as ambulatory setting becauseit is specifically designed to support health information systems byaiding point of care documentation. It increases the effectiveness ofhealth information system by promoting “interactive, interrelatedand continuous feedback process”. The pillars of Clinical CareClassification taxonomy are diagnosis, interventions and outcomes(Saba, 2007).

References

MichelleA. (2010). CPT2011 Standard Edition.American Medical Association Press. ISBN 978-1-60359-216-1.

Saba,V. K. (2007). ClinicalCare Classification (CCC) System manual: A guide to nursingdocumentation.New York: Springer Publishing.

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