Formal standards in healthcare have derived from the need to develop a standardized system for informal applications within hospitals (Laureate Education, 2010). For example; hospital pharmacies, medical billing and clinical staff required an application to accomplish patient care in an ever growing field of information technology. Standards in healthcare were created to make processes work more efficiently (Hammond, Cimino, 2006) and comprise a set of rules and definitions that specify exactly what something is. In healthcare, specifically a hospital environment, a formal standard is useful because it permits two or more disassociated departments such as clinicians and pharmacies along with the billing department to work together in a cooperative way.
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Patients receive care in primary, secondary, and tertiary care settings, (Hammond, Cimino, 2006) with most communication centered on the patient's chart. Patients are cared for by physicians within the hospital and those doctors most likely will prescribe medications and place orders for labs and possibly procedures; x-rays, cat-scans, etc. for that patient during their stay. A doctor may consult with another physician to discuss the condition or treatment of a patient and by the means of this communication an industry standard of terminology must exist. Thus, the encoding of clinical knowledge using an accepted standard would allow many people and institutions to share the work done by others (Laureate Education, 2010). An approach to creating the development of medical coding or standards has been developed and named
Patients receive care in primary, secondary, and tertiary care settings, (Hammond, Cimino, 2006) with most communication centered on the patient's chart. Patients are cared for by physicians within the hospital and those doctors most likely will prescribe medications and place orders for labs and possibly procedures; x-rays, cat-scans, etc. for that patient during their stay. A doctor may consult with another physician to discuss the condition or treatment of a patient and by the means of this communication an industry standard of terminology must exist. Thus, the encoding of clinical knowledge using an accepted standard would allow many people and institutions to share the work done by others (Laureate Education, 2010). An approach to creating the development of medical coding or standards has been developed and named