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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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.
|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:||Schools > School of Nursing, Midwifery, Social Work & Social Sciences > Centre for Nursing, Midwifery, Social Work & Social Sciences Research
Schools > School of Nursing, Midwifery, Social Work & Social Sciences
|Journal or Publication Title:||Urologic Nursing|
|Depositing User:||Institutional Repository|
|Date Deposited:||19 May 2011 09:34|
|Last Modified:||30 Nov 2015 23:46|
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