The clinical terms project: its potential for computerised surgical audit

Abstract

Computerised surgical audit requires accurate and detailed clinical information on individual patients. This requires a standardised language which can be understood and used by both clinicians and computers. The present system of classifying patients using OPCS and ICD coding systems does not allow this because both are awkward and imprecise. The clinical terms project was set up to overcome these problems. Its aim was to develop a complete medical thesaurus of terms which medical and paramedical disciplines could use in their own practice. To audit activities in general surgery one needs to be able to record diagnostic information, operative procedures, investigations, therapeutic actions, non-operative procedures, etc. Such information needs to be recorded with various levels of detail depending on the degree of specialisation of the surgeon involved (eg, a general versus a highly specialised surgeon). In addition data needs to be cross-mapped to national classification systems (ICD, OPCS). To provide the level of clinical detail required it has been found necessary to separate terms into a 'main core term' and 'qualifying terms'. This has resulted in a shorter but more comprehensive thesaurus of clinical terms which will enable rapid and consistent data transfer between different computer systems.