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Terminology use in electronic health records: basic principles

Watkins, TJ, Blundberg, C, Brokel, J, Wilson, M and Hardiker, NR 2009, 'Terminology use in electronic health records: basic principles' , Urologic Nursing, 29 (5) , pp. 321-327.

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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.

Item Type: Article
Uncontrolled Keywords: Nursing terminology, nursing classification, nursing process, clinical content standards, evidence-based practice, regulatory compliance, electronic health record (EHR)
Themes: Subjects / Themes > R Medicine > RT Nursing
Health and Wellbeing
Schools: Colleges and Schools > College of Health & Social Care > School of Nursing, Midwifery, Social Work & Social Sciences > Centre for Nursing, Midwifery & Social Work Research
Colleges and Schools > College of Health & Social Care
Colleges and Schools > College of Health & Social Care > School of Nursing, Midwifery, Social Work & Social Sciences
Journal or Publication Title: Urologic Nursing
Publisher: Mosby
Refereed: Yes
ISSN: 1053-816X
Related URLs:
Depositing User: Institutional Repository
Date Deposited: 19 May 2011 09:34
Last Modified: 20 Aug 2013 16:48
URI: http://usir.salford.ac.uk/id/eprint/13987

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