Law & EHRS

Advance for Health Information Professionals • January 2017

7 JANUARY 2017 C O D I N G Leaping Into the Future SNOMED CT for clinical documentation By Samm Anderegg, PharmD, MS, BCPS Codified clinical documentation is vital to the future of healthcare and improving patient outcomes. Pharmacists are emerging as a core member of the healthcare team, providing direct patient care by optimizing medication regimens and managing patients with chronic disease. Pharmacists and other healthcare professionals can enrich clinical data by leveraging health information technology (IT) standards and recording detailed clinical documentation. Documentation codes transform information typically written or typed as progress notes into discrete data points structured to describe the care provided to an individual patient. Data can be exchanged, reported and analyzed to identify high-risk patient populations and determine which services optimize outcomes. Electronic record systems already capture many types of information as discrete data, including diagnoses, THINKSTOCK ADVANCE FOR HEALTH INFORMATION PROFESSIONALS / CODING


Advance for Health Information Professionals • January 2017
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