Clinical terminologies consist of concepts that support which of the following facets of health care? Select all that apply
1. Diagnostic studies
2. History and physical examinations
3. Visit notes
4. Ancillary department information
5. Outcomes measures
1,2,3,4,5
Rationale: Clinical terminology enables the capture of data at the level of detail necessary for patient care documentation and is used to describe health conditions and health care activities (ISO/IEC 17115, 2007). Clinical terminologies consist of concepts that support diagnostic studies, history and physical examinations, visit notes, ancillary department information, nursing notes, assessments, flow sheets, vital signs, and outcome measures. A clinical terminology can be mapped to a broader classification system for administrative, regulatory, and fiscal reporting requirements (Giannangelo, 2010, p. 3).
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