Abstract
The concept of standardization is pervasive in discussions about computer data and its exchange across networks for the purposes of abstraction, aggregation and summarization. Within the context of standardization, the most commonly discussed issues include standard formats for the electronic transfer of clinical data (McDonald & Hammond, 1989); standardized, uniformly coded minimum data sets (Gabrieli, 1985), including the nursing minimum data set (Werley & Lang, 1988); and uniform coding systems such as ICD-9, CPT-4, DRGs and SNOMED, that are currently in use. Respectively, these latter standardizing systems are used for the purposes of classifying causes of mortality, providing reimbursement, and summarizing pathology reports. Others have described standardizing data sets, that is, the information content and procedures for establishing a research oriented database (Thompson, Piland, Hoy, Watkins & Montgomery, 1990).
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References
Gabrieli, E. R. (1985). Standardization of medical informatics. Journal of Clinical Computing, 14 (3), 62–104.
Grobe, S. J. (1990). Nursing intervention lexicon and taxonomy study: Language and classification methods. Advances in Nursing Science, 13 (2), 22–34.
McDonald, C. J. & Hammond, W. E. (1989). Standard formats for electronic transfer of clinical data. Annals of Internal Medicine, 110 (5), 333–335.
Thompson, B. D., Piland, N. F., Hoy, W. E., Watkins, M. & Montgomery, K. A. (1990). Standard information content and procedures used in the formulation of a research oriented health services database. In R. A. Miller (Ed.), SCAMC Proceedings: Fourteenth Annual Symposium on Computer Applications in Medical Care: Standards in medical informatics, pp. 359–363. Los Alamitos, CA: IEEE Computer Society Press.
Werley, H.. & Lang, N. M. (1988). Identification of the nursing minimum data set. New York: Springer Publishing.
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Grobe, S.J. (1991). Can Patient Care Documentation be Standardized for Today’s Computer?. In: Marr, P.B., Axford, R.L., Newbold, S.K. (eds) Nursing Informatics ′91. Lecture Notes in Medical Informatics, vol 46. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-46746-2_30
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DOI: https://doi.org/10.1007/978-3-642-46746-2_30
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