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Related Experiment Videos

The clinical terms project: its potential for computerised surgical audit

M A Tabaqchali1, C W Venables

  • 1Department of Surgery, Freeman Hospital, Newcastle-upon-Tyne.

Annals of the Royal College of Surgeons of England
|May 1, 1995
PubMed
Summary

Developing a standardized medical thesaurus improves surgical audit by enabling precise data capture. This standardized clinical terminology facilitates accurate and consistent data transfer between computer systems for better patient information management.

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Area of Science:

  • Medical Informatics
  • Clinical Data Management
  • Surgical Auditing

Background:

  • Computerized surgical auditing necessitates accurate, detailed patient clinical information.
  • Current coding systems like ICD and OPCS lack the precision for detailed clinical data capture.
  • A standardized medical language is essential for both clinicians and computer systems.

Purpose of the Study:

  • To develop a comprehensive medical thesaurus for standardized clinical terminology.
  • To overcome the limitations of existing coding systems (ICD, OPCS) for surgical auditing.
  • To enable detailed recording of diagnostic, operative, and therapeutic information for surgical audits.

Main Methods:

  • Creation of a medical thesaurus with 'main core terms' and 'qualifying terms'.

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  • Separation of terms to allow for varying levels of clinical detail based on surgical specialization.
  • Cross-mapping of data to national classification systems (ICD, OPCS).
  • Main Results:

    • A shorter, more comprehensive thesaurus of clinical terms was developed.
    • The new thesaurus allows for recording of diverse surgical information with appropriate detail.
    • Facilitates rapid and consistent data transfer between different computer systems.

    Conclusions:

    • The developed thesaurus provides a standardized language for detailed clinical information in surgical auditing.
    • This approach enhances the accuracy and consistency of data transfer for better patient record management.
    • The 'main core term' and 'qualifying term' structure supports specialized data needs in surgery.