Terminology use in electronic health records: basic principles

Watkins, TJ; Blundberg, C; Brokel, J; Wilson, M; Hardiker, NR

Abstract

Electronic health records (EHRs) are a cost-saving and environmentally friendly means for documenting patient care and improving patient safety, quality, and evidence-based practice. Standardized clinical classification systems and terminologies are essential ingredients of the EHR. Their selection must be driven by a clear understanding of requirements for their use and application. This article
describes the principle uses of clinical information and motives for consistency in practice, and provides a distinction between classification systems and reference terminologies for clinical settings.

Citation

Watkins, T., Blundberg, C., Brokel, J., Wilson, M., & Hardiker, N. Terminology use in electronic health records: basic principles. Urologic nursing, 29(5), 321-327

• Journal Article Type: Article
• Deposit Date: May 19, 2011
• Journal: Urologic Nursing
• Print ISSN: 1053-816X
• Peer Reviewed: Peer Reviewed
• Volume: 29
• Issue: 5
• Pages: 321-327
• Keywords: Nursing terminology, nursing classification, nursing; process, clinical content standards, evidence-based; practice, regulatory compliance, electronic health; record (EHR)
• Related Public URLs: http://www.suna.org/education/2011/article29321326.pdf