TJ Watkins
Terminology use in electronic health records: basic principles
Watkins, TJ; Blundberg, C; Brokel, J; Wilson, M; Hardiker, NR
Authors
C Blundberg
J Brokel
M Wilson
NR Hardiker
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 |