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ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
ssues and Trends in HBI Ch15 pp
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ssues and Trends in HBI Ch15 pp

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  • 1. Handbook of Informatics for Nurses & Healthcare Professionals Fifth Edition CHAPTER 15 The Role of Standardized Terminology and Language in Informatics Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 2. Learning Outcomes1. Understand what standardized healthcare terminology is and why it is important to nursing.2. Describe the American Nurses Association (ANA) recognition criteria established for recognizing standardized terminologies. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 3. Learning Outcomes3. Describe each of the ANA recognized terminologies and the benefits of use when implemented within an electronic healthcare record.4. Discuss standardized terminologies used for the different parts of the nursing process and their similarities and differences. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 4. Learning Outcomes5. Define the different types of terminology structures, such as a classification system (e.g. NANDA, NIC, NOC) versus a reference terminology (ICNP, SNOMED-CT).6. Demonstrate how standard terminologies facilitate the use of evidence-based practice and decision- support rules. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 5. Learning Outcomes7. Illustrate how using standardized healthcare terminologies correlates to the U.S. meaningful use criteria.8. Identify the benefits of using structured terminologies within electronic healthcare records. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 6. Standardized Terminology• Structured and controlled languages that have been developed and approved by an authoritative body Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 7. Healthcare Terminology Standards • Designed to enable and support widespread interoperability and for the purpose of sharing information • Essential to the widespread implementation of EHRs Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 8. Meaningful Use• The goal is to exchange clinical structured data in a manner that is accurate and complete to improve client care in a cost-efficient way. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 9. Terminology Definitions• Concepts• Codes• Clinical terminology Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 10. TABLE 15–1 Types of Healthcare Terminologies Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 11. TABLE 15–2 Cimino’s 12 Terminology Development Guidelines Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 12. Terminology and Nursing• Need a standardized nursing language that is common to all nurses Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 13. Languages and Classifications• Billing codes set by HIPAA• International Classification of Disease (ICD) developed by World Health Organization• Current Procedural Terminology (CPT) developed by American Medical Association Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 14. TABLE 15–3 Examples of ICD-9-CM Codes Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 15. TABLE 15–4 Examples of CPT Codes Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 16. Clinical Terminology• Unified Medical Language System (UMLS) developed by National Library of Medicine Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 17. Clinical Terminology• American Nurses Association recognizes terminology for use by nurses – Clinical Care Classification (CCC) – North American Nursing Diagnosis Association International (NANDA-I) – Nursing Intervention Classification (NIC) – Nursing Outcome Classification (NOC) – Omaha System – SNOMED CT Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 18. SNOWMED CT• Globally recognized terminology• Promotes evidence-based practice• Undergoes review process to keep up to date Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 19. LOINC• Logical Observation Identifiers, Names, and Codes• Laboratory and clinician observations terminology• Nursing content found in one domain Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 20. Clinical Care Classification System • Design based on six steps of nursing process • 182 diagnostic concepts • Subcategories represent interventions, procedures, treatments, and activities Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 21. International Classification of Nursing Practice• Contains diagnoses, actions, and outcomes Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 22. TABLE 15–9 ICNP Axes With Examples Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 23. NANDA International• Was the first nursing terminology recognized by ANA• Can be actual or potential health problem• Contains nursing diagnoses defined by signs and symptoms Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 24. Nursing Interventions Classifications• Describe interventions used in nursing care• Seven domains of interventions• Can be used in an electronic health record Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 25. Nursing Outcomes Classifications• Describe outcomes related to nursing interventions• Seven domains of outcomes• Can be used in an electronic health record Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 26. Omaha System• Research-based taxonomy• Assessment component—Problem Classification Scheme• Intervention component—Intervention Scheme• Outcomes component—Problem Rating Scale for Outcomes Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 27. PeriOperative Nursing Data Set• Developed by Association of periOperative Registered Nurses (AORN)• Composed of nursing diagnoses, interventions, and outcomes Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 28. Benefits of Implementation• Client-specific benefits – Decreased costs – Increased quality – Improved outcomes – Improved safety Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 29. Benefits of Implementation• Provider/Nursing Benefits – Complete access to data – Increased efficiency – Increased accuracy – Increased effectiveness – Improvement in client care Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 30. Benefits of Implementation• Organizational – Decreased costs – Decision support – Outcome measurement – Data mining Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar
  • 31. Future Directions• Clinical Observations Recording and Encoding (CORE) developed by National Library of Medicine will be used.• Health information technology will increase communication between provider and client. Handbook of Informatics for Nurses & Healthcare Professionals, Fifth Edition Toni Hebda • Patricia Czar

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