02 — Capability · BC-1880.40
Clinical Terminology
Keep the clinical vocabularies, code sets and local dictionaries the organization uses current and mapped to national standards, so data means the same thing in every system and report. Assigning codes to encounters for billing is clinical coding.
- Terminology Services
- Clinical Vocabulary
- Code Set Management
In scope
- Standard code set loading and version updates
- Mapping local terms to standard vocabularies
- Value sets for measures, registries and decision rules
- Terminology governance and dictionary change control
Out of scope
- Assigning diagnosis and procedure codes to encounters (see BC-1840.20)
- Enterprise reference and master data in general (see BC-750.40)
- Chargemaster and charge codes (see BC-1840.10)
Realized by · 0
- No product in the catalog yet.
Used in · 0
- Not yet placed on a value stream.
Build it · 1
Governed by · 1
Decomposes into · 4
- BC-1880.40.10Code Set MaintenanceLoad and test new releases of national code sets and classifications by their effective dates, and retire outdated codes.
- BC-1880.40.20Terminology MappingMap local terms for tests, problems and observations to standard vocabularies so data can be shared and compared.
- BC-1880.40.30Value Set AuthoringDefine and maintain the groups of codes that quality measures, registries and decision rules rely on.
- BC-1880.40.40Terminology GovernanceDecide who may add or change clinical terms and dictionary entries, and review each request so the vocabulary stays consistent.