Standardized Healthcare Terminology
Week 6 Discussion
Standardized Healthcare Terminology Used in Electronic Health Record Systems (EHRS)
Patient-centered care requires treating patients in a variety of settings across the entire healthcare continuum and therefore, necessitates the ability to communicate and share the most accurate and up-to-date-information among a multitude of providers and settings. Information has evolved from paper-based to computerized records. The introduction of computerized information systems has increased the need for structured and controlled vocabularies that can be used to represent care in electronic health records.
A. Explain standardized healthcare terminology and its importance to nursing. Describe the American Nurses Association (ANA) criteria established for recognizing standardized languages used in electronic documentation in the electronic health record (EHR) that support nursing practice and how these nursing languages support the nursing process.
B. Identify two of the ANA-recognized languages you implement in your nursing practice in your electronic health record (PNDS and NOC are the ones I use in my practice). Discuss how they support high quality patient care and facilitate the implementation of evidence-based practice and decision-support rules. If you are not currently using computerized health information systems, identify two of the standardized nursing terminologies that are used in electronic health records you feel best support high quality patient care and facilitate the use of evidence-based practice and decision-support rules.
C. Explain how standardized terminologies correlate to and support the Meaningful Use criteria for electronic health records (EHRs).
References:
1. Scholarly nursing journal published in the last 5 years.
2. Hansdbook of informatics for nurses and healthcare professionals 6th edition 2019 ISBN: 978-0-13-471101-0 Chapter 15 p. 293-319
All components are required to be answered comprehensively as one discussion response in your initial post. Do not separate the answers and respond to each question individually.
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