1. How would you define standardized terminologies and why are they important? Provide an example in your answer.
A standardized terminology is simply a basic word that describes or explains in a simplest ways for everyone to understand. Usually standardized terminologies everyone knows about because it is a part of the communication. Reason why standardized terminologies is important if you understand the concept of the term, both partner will understand what each other talking about and there will be no miscommunication. In nursing, there are many standardized terminologies that is use everyday. The simplest terminology is the basic vital signs such as blood pressure (BP), respiratory rate (RR), tachycardia or bachycardia (high or low pulse). These terms are used when giving rounds or will be see often in patients chart. 2. What are some of the advantages and disadvantages to having a standardized terminology within electronic health record
Advantages: Fast and simple – Easy to understand – With different EHR programs (EPIC or Powerhcart) all the standardized terminology are the same – Not only nursing understand the terms but other healthcare providers will also – There should be no assumption what the terms mean because it’s a universal terms in all EHR. Disadvantages: Other EHR might have different terminology prior to
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Within this two terms, it work together to help delivery patient care within the hospital or the team that is caring for the patient. Interface will be the systems that spread out the information to a bigger group such as the interoperability, and from there the interoperability will be the one that helps share the information to the organization or the team. With two works together to help the communication between the groups to provide good quality care for the
...benefits of this type of clinical decision support system include easy access to information and patient records, provision of timely support throughout the care process, reduced costs, enhanced efficiency, and reduced patient inconvenience. However the disadvantages include potential difficulties in interpreting information, difficulties in handling the huge amount of nursing literature, and probability of additional demands to care process.
• Provides a basic level of interoperability among electronic health records (EHRs) maintained by individual physicians and organizations
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
The federal government has taken a stance to standardized care by creating incentive programs that are mandated under the Health Information Technology for Economic and Clinical Health Act (HITECH) of 2009. This act encourages healthcare providers and healthcare institutions to adopt Meaningful use in order to receive incentives from Medicare and Medicaid. Meaningful use is the adoption of a certified health record system that acquires or obtains specified objectives about a patient. The objectives or measures are considered gold standard practices with the EHR system. Examples of the measures include data entry of vital signs, demographics, allergies, entering medical orders, providing patients with electronic copies of their records, and many more pertinent information regarding the patient (Friedman et al, 2013, p.1560).
The health information networks factor into the enhancement of the patient-centered management system, in that they help with the implementation of the Electronic health record. The HITECH Act for example allocated “18 billion through the Medicare and Medicaid reimbursement systems as incentives for hospitals and physicians who are meaningful users of EHR systems”(About the HITECH, n.d.). This is a beneficial way to promote the use of electronic health records and have them become universally utilized across the nation. NHIN is also an excellent network that is more widespread and contains policies as well as standards that help with the safe trade of data. NHIN is the biggest network that all other health information networks hope to achieve. The NHIN is a contributor to the expansion of the EHR and it also further improves the patient-centered management system by having the policies they have. These policies assist with keeping the information in the system safe and also helping many different entities to become a part of its use. Some of the entities involved are the Center for Disease Control and prevention, Social Security Administration, Department of Defense and Kaiser Permanente among others. Both CHIN and RHINO implement the use of electronic health record, which makes it more widespread,
A few added helpful things it does is: installs quickly, lets patients do more, and is more profitable. Epic has been named the number one overall best software in 2013. It continues to get great ratings about how quick they are. Epic system also is not only helpful to the employees it is also very useful for the patients. Like I mentioned in a prior statement, Epic system allows patient to be able to log in and see their history of health. This helps the patient because they can keep track of all of their medical history, as well as print off the information they may need instead of going through the actual facility. According to a Nurse colleague of mine, I had interviewed her about this product. She says “it is a great system and very easy to work with.” She claimed it helps out a lot to have the e-learning class to jump start on the system when you’re a new employee. At her current location, all the employees love the system, and love to be able to learn hands on from day one of
“Meaningful Use” implemented in July, 2010, set criteria’s for physicians and hospitals to adhere, in order to qualify for certain financial incentives and to be deemed meaningful users (MU) of the EMR. Meaningful use in healthcare is defined as using certified electronic health record to improve quality, safety, efficiency, and reduce mortality and morbidity. There are 3 stages of meaningful use implementation. The requirements for the 3 stages are spread out over a period of 5 years. MU mandates that physicians meet 15 core objectives and hospitals meet 14 core objectives (Hoffman & Pudgurski, 2011). The goal is to in-cooperate the patient and family in their health, empower autonomy to make decisions while improving care in all population.
The 'Standard' of the 'Standard'.
This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
The 'Standard' of the 'Standard'
The purpose of the Electronic Health Record is to provide a comprehensive, standardized and universal digital version of a patient 's health records. The availability of a patient 's digital health record provides health information and data for critical thinking and evidence based decision-making, aggregates patient data for quality assurance and research. The Electronic Health Record has been, "identified as a strategy for effectively and efficiently coordinating and maintaining documentation of patients health histories and as a secure method of providing more informed clinical decision making" (MNA, 2006).