Healthcare standards are essential to development and implementation of Electronic Medical Record (EMR), Representation of healthcare data in a standard will help in reaching better interoperability. I will track patient admission until discharge with diagnosis of Angina.
As a clinician I will diagnose this patient using Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT), the EMR or the coders should then map my diagnosis into international Classification of Diseases Clinical Modification 10th edition (ICD-10- CM)) using the Interactive Map-Assisted Generation of ICD Codes (I-MAGIC) (I-MAGIC], 2015). SNOMED-CT is required in stage 2 and should be used for documenting problem (Levy, 2013a). SNOMED-CT is a comprehensive clinical terminology that describe the diagnosis in details, it is way of description is close to the medical language. SNOMED-CT easy to map to other clinical terminology like ICD-9 and ICD-10 in a addition to LOINC (Giannangelo, 2015)., The SNOMED-CT code for Angina is 194828000, and the ICD-10-CM for Angina is I24.9, Acute ischemic heart disease (NLM, 2013).
At admission the physician need to order Electrocardiogram (EKG) test to confirm angina, EKG was ordered and EMR attached the Current Procedural Terminology (CPT), CPT was developed by the American Medical Association (AMA) it doesn’t contain diagnosis codes it only focuses in procedures, the CPT code for EKG 12 leads is 93000 (Giannangelo, 2015; ECG CPT, 2015).
The physician placed an order for for aspirin as first choice medication for chest pain treatment (American Heart Association, 2015). The medication is coded using the RxN1. RxN1 is the medication name and it synonym in RxNorm. RxN1 is a meaningful Use (MU) stage II standard for medication and allergy (Giannangelo, 2015).
After few days the patient improved and his condition is more stable, the physician decided to