Classifications, Vocabularies, and Terminologies: Clinical Standards, Part II

A classification system, such as the International Classification of Diseases or the Diagnostic and Statistical Manual of Mental Disorders, is a health information standard that involves the arrangement or categorization of like or related entities; the relationally grouped details of classification systems are useful to providers in the delivery of care because they provide clinical information output that can be used in patient diagnosis and treatment. Conversely, a terminology, such as the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT®) or Current Procedural Terminology (CPT®), is a comprehensive set or collection of terms that represents a particular system of concepts for a certain subject area or field of interest. As such, terminologies as a standard are well-suited to capturing provider input of detailed clinical information into patient records, which, in turn, provides an ideal framework for data reporting and data comparison across records.

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