Informatics Ch 15 – Flashcards
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Standardized terminology
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Structured and controlled languages that have been developed and approved by an authoritative body Referred to as controlled terminologies
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Terminology standards
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Designed to enable and support widespread interoperability and for the purpose of sharing information Essential to the widespread implementation of EHRs
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Meaningful use
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Directly related to standardized health care terminologies Requirements mandate the use of standardized terminologies for data collection and reporting of established quality 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
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Concepts
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Terminology definition Expression with a single unambiguous meaning. One or more representations called synonyms or terms. Used to document ideas and express orders, assessments, and outcomes; Uniquely identified by codes.
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Codes
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Terminology definitions Letters, numbers, or a combination Represents concepts in a computer system.
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Clinical terminology
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Terminology definitions Support clinical concepts such as diagnostic studies, history and physical examinations, visit notes, ancillary department information, nursing notes, assessments, flow sheets, vital signs, and outcome measures. Can be mapped to a broader classification system for administrative, regulatory, and fiscal reporting requirements -Document patient care within the EHR -Unified Medical Language System (UMLS) developed by National Library of Medicine
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Reference terminology
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Terminology in EHR system Consists of a set of concepts with definitional relationships
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Point of care terminology
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Terminology in EHR system Referred to as an interface terminology, is what the clinicians see on the screen and consists of terms with which clinicians are familiar
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Nomenclature
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A set of terms composed according to pre established rules
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Terminology
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A set of terms representing concepts in a particular field or domain, for example, problems, observations
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Vocabulary
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A terminology accompanied by definitions or descriptions
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Classification
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An arrangement of concepts based on essential characteristics, arranged in a single hierarchy
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Ontology
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A set of concepts formally organized by meaning
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ICD (International classification of disease)
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Developed by World Health Organization ICD-9-CM ICD-10
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CPT (Current procedural terminology)
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Developed by American Medical Association Billing and reimbursement of outpatient procedures and interventions
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AMA terminology
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Clinical Care Classification (CCC) North American Nursing Diagnosis Association International (NANDA-I) Nursing Intervention Classification (NIC) Nursing Outcome Classification (NOC) Omaha System SNOMED CT
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Nursing process
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Assessment--> Nursing diagnosis--> Planning--> Implementation--> Evaluation--> Assessment
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Snowmed CT
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Globally recognized terminology Undergoes review process to keep up to date Benefits to use in EHR
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LOINC
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Logical Observation Identifiers, Names, and Codes Laboratory and clinician observations terminology Nursing content found in one domain -In 2002, LOINC was recognized by ANA -Identify and name for observations, not values
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ICNP (International classification of nursing practice)
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Nursing terminologies Contains diagnoses, actions, and outcomes Seven-axis model
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NIC (Nursing interventions classifications)
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Nursing terminologies Describe the activities that nurses perform. 542 interventions, 30 classes and 7 domains used within the EHR, mapped in SNOMED CT, NAND-1, NOC
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NOC (Nursing outcomes classifications)
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Nursing terminologies Describe patient outcomes sensitive to nursing interventions. 330 patient outcomes, 31 classes and 7 domains used within the EHR, mapped in SNOMED CT, NAND-1, NIC
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PNDS (PeriOperative Nursing data set)
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Nursing terminologies Developed by Association of periOperative Registered Nurses (AORN) Composed of nursing diagnoses, interventions, and outcomes
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CCC system (Clinical care classification system)
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Design based on six steps of nursing process It facilitates patient care documentation at the point of care. Integrated language - diagnoses, interventions & outcomes Mapped to SNOMED CT Developed by Saba (Georgetown University) 182 diagnostic concepts 126 Subcategories represent interventions, procedures, treatments, and activities
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NANDA international
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Was the first nursing terminology recognized by ANA used to document nursing diagnoses within all settings and across the care continuum. Can be actual or potential health problem Contains nursing diagnoses defined by signs and symptoms can be used within the EHR. Linked to the NIC interventions and NOC outcomes. Cross mapped in SNOMED CT 13 domains, >26 classes.
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Omaha system
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Research-based taxonomy -Developed by the Omaha VA & Karen Martin for Home Care, Public Health, & Community Assessment component: Problem Classification Scheme -42 client problems --4 domains (environmental, psychosocial, physiological, health related behaviors) Intervention component: Intervention Scheme -75 targets for nursing interventions --4 categories (health teaching, guidance & counseling, treatments & procedures, case management, surveillance) Outcomes component: Problem Rating Scale for Outcomes -3 subscales (knowledge, behavior, status)
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Client benefits
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Benefit of terminology implementation Decreased costs Increased quality Improved outcomes Improved safety
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Nursing benefits
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Benefit of terminology implementation Complete access to data Increased efficiency Increased accuracy Increased effectiveness Improvement in client care
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Organization benefits
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Benefit of terminology implementation Decreased costs Decision support Outcome measurement Data mining
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Problems
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Mapping considerations, Determination of the most suitable terminologies, Retrofitting standardized terminologies into existing system
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Future
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Clinical Observations Recording and Encoding (CORE) developed by National Library of Medicine will be used. Health information technology will increase communication between provider and client.
