Standardized Terminologies in Health Care Databases

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To prepare:

  • Review this week’s Learning Resources focusing on the significance of standardized terminologies in health care settings. Consider how standardized terminologies are important in the development and use of databases and clinical information systems.
  • Explore the websites of major health care organizations to determine their recommendations on acceptable standardized terminologies.
  • Determine the standardized terminologies currently used by your health care organization (or one with which you are familiar).
  • Consider the standard terminologies (recommended by a major medical organization or based on your experiences) you would like to see incorporated into your organization’s databases and clinical information systems. What would be the benefit of using these particular standards? How might this impact the quality of the information retrieved from databases within your organization?

THEN

Post a description of at least one standardized terminology that is recommended by a major health care organization. Assess how or if this terminology is incorporated into your organization’s databases and clinical information systems. Identify at least one additional standardized terminology you would like to see incorporated into the organization’s databases. Analyze the importance of incorporating this terminology and how this could impact the quality of the data retrieved from the databases. Justify your response.

Use these references:

http://library.ahima.org/doc?oid=92186

Dontje, K., & Coenen, A. (2011). Mapping evidence-based guidelines to standardized nursing terminologies. Computers, Informatics, Nursing, 29(12), 698–705.

Hayrinen, K., Lammintakanen, J., & Saranto, K. (2009). Evaluation of electronic nursing documentation—nursing process model and standardized terminologies as keys to visible and transparent nursing. International Journal of Medical Informatics, 79(8), 554–564.

Thoroddsen, A., Ehnfors, M., & Ehrenberg, A. (2011). Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records. Computers, Informatics, Nursing, 29(10), 599–607.

Frisher, M., Short, D., & Bashford, J. (2010). Determining patient characteristics for decision analysis support systems using anonymized electronic patient records. Health Informatics Journal, 16(1), 49–57.

Huryk, L. A. (2012). Information systems and decision support systems. American Journal of Nursing, 112(1), 62–65.

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