Which standardized nomenclature is an example of textual knowledge for concepts in nursing

Standardized Terminology – Why is it Important?

Agencies are rushing to adopt EHRs to meet rapidly evolving federal, state, local, program, and grant mandates regarding electronic documentation.

In researching public health agency EHR software options, you will find a key difference among them:

• Some are based on standardized terminologies while others are not

Read our recent articles which discuss what does standardized terminology in healthcare really mean, and what criteria should a standardized terminology meet for more information about what standardized terminology means.

What are your program goals?

If your program goals include the ability to measure client outcomes to clinician interventions in a reliable and valid way, you should consider purchasing software based on a standardized terminology.

A standardized terminology is simply a common language, nomenclature, classification, or taxonomy designed to be shared among users.

In health care settings, use of standardized terminologies is essential to clearly and accurately document client assessments, care, and outcomes.

If you cannot describe your care to others using a commonly understood language, then you cannot effectively:

• Establish standards
• Influence policy
• Expect funding for your programs

What are the benefits of a Standardized Terminology?

There are many benefits to using a standardized terminology, including:

• Meeting mandated interoperability requirements and standards
• Facilitating communication among nurses and other health care workers
• Enabling the collection of shared data to improve health care at the local level and beyond
• Adhering  to standards of care and best practices, especially with the concurrent use of shared pathways
• Evaluating the effectiveness of community health care at all levels through measurement of outcomes
• Giving better visibility to your work

What is a good example of a Standardized Terminology?

One example of an internationally-used standardized terminology is the Omaha System.

This standardized terminology is a leader among its peers in meeting the stringent criteria necessary for full integration and interoperability in electronic health records.

One of the first clinical nomenclatures to be developed, the Omaha System is a research-based and provides interoperability and communication across the continuum of community health: health clinicians, administrators, educators, and researchers.

The Omaha System is composed of three essential components to describe care:

1. The Problem Classification Scheme (assessment)
2. The Intervention Scheme (interventions/clinician actions)
3. The Problem Rating Scale for Outcomes (measurement of outcomes).

Learn more by reading our blog post What Is The Omaha System and What Does It Offer You?

You can read more about the Omaha System at www.omahasystem.org. You will find a valuable overview of the system, publications, FAQ’s, case studies, references, links, conferences, and the Omaha System Listserv.

Conclusion

Now you know more about Standardized Terminology, why not Contact Us at (507) 388-4141 to tell us what you need your EHR software to do. Nightingale Notes might be just what you’re looking for.

Download our eBook, “Standardized Terminology for EHRs” to learn more about what criteria standardized terminology should meet so that you know what to look for when choosing a standardized terminology for your EHR.

Check out the references below for even more information about standardized terminologies and Omaha System users! You can also download our free ebook, Evaluating Standardized Terminology in EHR: Communicating What You Do.

References:

• Martin KS. (2005). TheOmaha System: A Key to Practice, Documentation, and Information Management(Reprinted 2nd ed.). Omaha, NE: Health Connections Press.  http://www.healthconnectionspress.com/book2005.html
• Rutherford, M. (Jan 31, 2008) “Standardized Nursing Language: What Does It Mean for Nursing Practice?” OJIN: The Online Journal of Issues in Nursing.  Vol 13 No. 1 http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/ vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursingLanguage.aspx
• Thede, L. (Aug 18, 2008) “The Electronic Health Record: Will Nursing Be on Board When the Ship Leaves?”  OJIN: The Online Journal of Issues in Nursing Vol 13 No. 3. http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Informatics/ElectronicHealthRecord.aspx
• Westra BL, Oancea C, Savik K, Marek KD. (2010, May/June). “The feasibility of integrating the Omaha System data across homecare agencies and vendors.” CIN: Computers, Informatics, Nursing, 28(3), 162-171. http://journals.lww.com/cinjournal/Abstract/2010/05000/The_Feasibility_of_Integrating_the_Omaha_System.9.aspx
• Zielstorff, R. (September 30, 1998). “Characteristics of a Good Nursing Nomenclature from an Informatics Perspective.”   OJIN: The Online Journal of Issues in Nursing Vol 3 No. 2.
• http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol31998/No2Sept1998/CharacteristicsofNomenclaturefromInformaticsPerspective.aspx

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Nicole has worked at Champ for over a decade, and is the Chief Operations Officer, and oversees all the day to day operations here. When she’s not spending time at work with her Champ family, Nicole and her husband Jake, and their 3 kids, Allison, Isaac, and Jacob, enjoy camping, hiking, biking, swimming, as well as running to volleyball, basketball, and football camps and games.

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