Common nursing terminology for clinical information systems

Area of Science:

• Nursing Informatics
• Health Information Systems
• Clinical Terminology

Background:

• Lack of standardized nursing terminology hinders the effectiveness of Clinical Information Systems (CIS) as patient health record repositories.
• Professional disagreement on terminology impacts data consistency and interoperability in healthcare.

Purpose of the Study:

• To identify common terminology for clinical nursing information within CIS.
• To implement standardized nursing terminology into computerized applications across diverse healthcare settings.

Main Methods:

• Nurses identified common patient history and nursing intervention data based on experience and standards.
• Nursing assessments and outcomes were identified using evidence-based Clinical Guidelines (CGL) for severity criteria.
• Standardized terminology was implemented into CIS applications in community clinics, oncology, and delivery settings.

Main Results:

• A standard patient history for admission and discharge was developed.
• 62 nursing assessments/outcomes and 70 nursing interventions were identified, with high commonality (70%) between hospital and community settings.
• Implementation rates varied, with community clinics adopting 40% of assessments/outcomes and 84% of interventions into their CIS.

Conclusions:

• Standardized nursing terminology can be successfully identified and implemented into CIS.
• The developed terminology and its computerization enhance data consistency for patient health records.
• Further research into evidence-based clinical nursing outcomes is needed to refine CIS applications.