point (Passed) 2025 ACTUAL SOLUTION Western Governors
University
A1. PowerPoint Title
A2. Seven Standardized Terminologies
Understanding the importance use of standardized terminologies and classifications is
crucial role in improving data quality in HIM. It ensures that health professionals are consistent
at using the same language, clear and precise at understanding common medical terms and
concepts to avoid misinterpretation. It is important to be able to compare and combine data from
different sources in order to produce comparability statistics about population health, treatment
outcomes, and productivity measures. The use of Standardized terminologies and classification
systems improve better communication among healthcare professionals, staff, researchers, and
administrators to improve patient care. Interoperability is essential because they are the primary
source of sending and receiving data in healthcare. (Oachs & Watters, 2020).
Common Procedural Terminology (CPT) – provides uniform language that accurately describes
medical, surgical, and diagnostic services. CPT helps healthcare community communicate with
physicians, patients, hospitals, insurance about medical procedures. It is also beneficial to
patient’s medical chart reviews and claims processing.
Healthcare Common Procedure Coding System Level II Codes (HCPCS) –Level II codes
are five-character alphanumeric codes, codes that represent supplies, products and services
not included in the CPT codes. The correct use of codes ensures that healthcare providers
are accurately reimbursed for their services
International Classification of Diseases, 10th Revision (ICD-10) – it is a classification system
that incorporates greater clinical detail and specificity to provide better quality of data. Its detail
and specificity will allow accuracy in evaluating issues and tracking its disease entries trends.
National Drug Codes – universal product identifier for human drugs. NDC identifies the
manufacturer, drug name, dosage, strength, package size, and quantity. Each product has its own
specific codes so there are no duplicate codes to reuse.
Rxnorms – this functionality already proven to be significantly beneficial to decrease medication
errors, reduce duplicate prescriptions, and most importantly, improve high quality data and that
leads to patient safety.
Omaha Systems – it consists of three assessment components: problem classification scheme,
patient assessment. It helps health providers collect, document, sort, retrieve and communicate
health-related needs. Intervention scheme, is use to describe and provide health-related care
plans and practice to prevent illness, improve health, and/or provide comfort before death. Last
is problem rating scale for outcomes, an assessment to evaluate patients’ knowledge, behavior
and status throughout the period of service.
, SNOMED-CT – it provides standardized terms and their synonyms captured by the clinician. It is
designed to share records for electronic health information exchange. It is essential for recording
and sharing accurate clinical data such as patient problem list, medicine, medical conditions
documented in EHRs. Healthcare providers can streamline their information processes and save
time.
A3.
Organizational Policies or Processes
- Implement data governance frameworks
- Invest in Training
- Perform Regular Audits and Monitoring
Data quality is essential for supporting clinical decision-making. It is important to prioritize
data quality to improve data quality. Integrating data quality requirements into organizational
policies or processes is critical for ensuring that data is accurate, consistent, complete and
reliable for its intended use. Implementing a data governance framework provides a structured
approach to ensure that organizations maintain accurate and consistent data assets. For example,
utilizing standardized terminologies for documenting clinical data. By using a uniform format to
collect data ensure consistency across the organization.
Providing training and education help improve data quality in the organization policies or
processes. Training healthcare staff help improve documentation intake and enhance the
accuracy and consistency of clinical data. Ongoing training sessions ensure that the staff are
updated on new system, policy and procedures. Performing regular audits is crucial for ensuring
ongoing data quality improvement. Monitoring will help identify errors, inconsistencies and
discrepancies within the healthcare (CCD, 2023).