ch 15: the role of standardized terminology and language in informatics – Flashcards

standardized termin -structure and controlled languages that have been developed and approved by an authoritative body -referred to as controlled terminologies healthcare terminology standards -designed to enable and support widespread interoperability and for the purpose of sharing info -essential to the widespread implementation of ehr's

-directly related to standardized health care terminologies -requirements mandate the use of standardized terminologies for data collection and reporting of established quality of measures -the goal is to exchange clinical structured data in a manner that is accurate and complete to improve client care in a cost-efficient way in nursing: -need a standardized nursing language that is common to all nurses -better communication to the interdisciplilnary team -increase the visibility of nursing interventions -enhance data collection used to evaluate and analyze patient care outcomes -support greater adherence to standards of care -assess nursing competency

recognizes terminology for use by nurses: CCC, Nanda-i, NIC, NOC, omaha system, snomed ct ana recognized nursing classifications codify data used during the nursing process: planning, implementation, evaluation, assessment, nursing diagnosis

client-specific: -decreased costs -increased quality -improved outcomes -improved safety provider/nursing benefits -complete access to data -increased efficiency -increased accuracy -increased effectiveness -improvement in client care organizational -decreased costs -decision support -outcome measurement -data mining

snowmed ct -globally recognized terminology -undergoes review process to keep up to date document care by interdiscipinaary approach ex: clinical finidings: the result of a clinical observation, assessment, or judgment (pain) procedures: purposeful activites performing in provision of healthcare (dressing change) benefits to use in ehr -provide interoperable data collection -ebp -decision support rules -reporting of quality measures -administrative billing international classification of nursing practive (ICNP) -combine diagnoses, actions, and outcomes -seven axis model

clinical care classification (ccc) system -design based on 6 steps of nursing process it facilitates patient care documentation at the point of care integrated language-diagnoses, interventions and outcomes mapped to snomed ct developed by saba 182 diagnostic concepts 126 subcategories represent interventions, procedures, treatments, and activities NANDA-first nursing terminology recognized by ANA -used to document nursing diagnoses within all settings and across the care continum -can be actual or potential health problem -contains nursing diagnoses defined by signs and symptoms -can be used with ehr -linked to the NIC interventions and NOC outcomes -cross mapped in SNOMED ct 13 domains, > 26 classes Omaha system -research based taxonomy developed by omaha va and karen martin for home care -assessment component-problem classification scheme 42 client problems: 4domains (environmental, psychosocial, health related behaviors) -intervention component-intervention scheme 75 targets fro nursing interventions 4 categories (health teaching, guidance and counseling, treatments and procedures, case management, surveillance) -outcomes component-problem rating scale for outcomes subscales (knowledge, behavior, status) Nursing intervention classification (NIC) -descrie the activities that nurses perform -542 interventions, 30 classes and 7 domains -used with ehr, mapped in snomed ct, nand-1, noc Nursing Outcomes classifications (NOC) -describe patient outcomes sensitive to nursing interventions -330 patient outcomes, 31 classes and 7 domains -used with ehr, mapped in snomed ct, nand-1, nic

-directly related to standardized health care terminologies -requirements mandate the use of standardized terminologies for data collection and reporting of established quality measures -goal is to exchange clinical structured data in a manner that is accurate and complete to improve client care in a cost-efficient way