Across health care settings, many different terms are used to describe the same or similar conditions.

Across health care settings, many different terms are used to describe the same or similar conditions. For example, a bed sore may alternatively be called a pressure sore, a pressure ulcer, or a decubitus ulcer. While it may be fairly manageable for a nurse to make the connection among these terms, the same cannot be said for a computer system. Nurses have the ability to reason and reflect upon their clinical knowledge. Computer systems are linear, relying on user input to output information. When diverse terms are used, systems are unable to make the connections between the data. For this reason, the health care industry is vigorously moving towards the standardization of terminologies.

Learning Resources

Saba, V. K., & McCormick, K. A. (2015). Essentials of nursing informatics (6th ed.). New York, NY: McGraw-Hill.

· Chapter 8, “Standardized Nursing Terminology”

This chapter introduces the problems related to terminology and vocabulary standardization across the broader health care field. Nursing-specific.

· Review Chapter 7, “Health Data Standards: Development, Harmonization, and Interoperability”

Health standards, rules, and definitions are requirements for effective and efficient electronic health records (EHRs). This chapter explains various options for these areas and discusses how they can be incorporated into EHRs.

· Appendix A, “Overview of the Clinical Care Classification System”

In this chapter, the authors describe challenges in health care related to clinical care classification and terminology standards. These issues are analyzed and possible solutions are overviewed.

Scherb, C. A., & Weydt, A. P. (2009). Work complexity assessment, nursing interventions classification, and nursing outcomes classification: Making connections. Creative Nursing, 15(1), 16–22.

Retrieved from the Walden Library databases.

The authors of this article discuss the Work Complexity Assessment (WCA), a process that allows nurses to better understand interventions for patient care. The connection between the WCA, the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC) are also discussed.

Truran, D., Saad, P., Zhang, M., & Innes, K. (2010). SNOMED CT and its place in health information management practice. Health Information Management Journal, 39(2), 37–39.

Retrieved from the Walden Library databases.

This article focuses on the Systemized Nomenclature of Medicine – Clinical Terminology (SNOMED CT) and how it can be used to support electronic health records (EHRs). The authors describe how SNOMED CT can contribute to EHR improvement with regard to patient safety, quality care delivery, and decision support functionality.

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