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:	Schools > School of Health and Society > Centre for Applied Research in Health, Welfare and Policy Schools > School of Health and Society
Journal or Publication Title:	Urologic Nursing
Publisher:	Mosby
Refereed:	Yes
ISSN:	1053-816X
Related URLs:	http://www.suna.org/education/2011/artic...
Depositing User:	Institutional Repository
Date Deposited:	19 May 2011 09:34
Last Modified:	10 Aug 2017 03:03
URI:	http://usir.salford.ac.uk/id/eprint/13987

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