Standardized Terminologies in Health Care Databases

Have you ever traveled abroad and asked for directions from someone who did not speak your own language? Perhaps you unsuccessfully attempted to use Google Translate or tried gestures and hand signals to communicate your request. The ability to communicate in the same language greatly increases the likelihood of shared understanding.

In health care, having a standard terminology facilitates the flow of information. Just as two people who speak different languages have difficulty understanding one another, so will two databases that utilize differing sets of terminologies. Standardized, shared terminologies enable database systems to effectively communicate.

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?

Required 550 words in APA format with 3 references

1) A description of at least one standardized terminology that is recommended by a major health care organization. ( Examples of standardized nursing terminologies are NANDA International (NANDA-I) for nursing diagnoses, NIC for nursing treatments and procedures, and NOC for patient-sensitive outcomes).

2) Assess how or if this terminology is incorporated into your organization's databases and clinical information systems.

3) Identify at least one additional standardized terminology you would like to see incorporated into the organization's databases . (Examples of standardized nursing terminologies are NANDA International (NANDA-I) for nursing diagnoses, NIC for nursing treatments and procedures, and NOC for patient-sensitive outcomes.) Analyze the importance of incorporating this terminology and how this could impact the quality of the data retrieved from the databases. Justify your response.

Required Resources

Note: To access this week's required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Readings

Hammond, W. E., Jaffe, C., & Kush, R. D. (2009). Healthcare standards development: The value of nurturing collaboration. Journal of AHIMA, 80(7), 44-50. Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_043995.hcsp?dDocName=bok1_043995

The authors of this article explore the effect that differing standards have on the health care field and how collaboration can help move standardization processes forward.

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

Retrieved from the Walden Library databases.

This article explores ways to standardize data terminology and data storage for increased diagnostic and treatment efficiency. The authors evaluate the utilization of standardized nursing terminologies and evidence-based guidelines with depression cases to pinpoint efficient implementation techniques and techniques that can still be improved.

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.

Retrieved from the Walden Library databases.

The authors of this article discuss the relationship between nursing processes and the development of more complete and comprehensive electronic health records (EHRs). In addition, they evaluate the motivations behind standardizing data for universal comprehension and application.

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.

Retrieved from the Walden Library databases.

In this research study, the authors performed audits of patient records to examine issues regarding documentation terminologies in patient care. The study revealed the need for standardized nursing terminologies and the role of these terminologies in improving the accuracy of evidence-based diagnoses.
Media

Laureate Education, Inc. (Executive Producer). (2012). Standardizing nomenclature. Baltimore, MD: Author.

Note: The approximate length of this media piece is 6 minutes.

Roy Simpson describes the importance of standardizing clinical language using nomenclatures, or methods of coding clinical information.