NURS 419: Mastering Documentation and Standardized Nursing
Language
standard - correct answer ✔✔an agreement to use a govern protocol, term, or other criterion formally
approved by a nationally or internationally recognized professional trace association or governmental
body
standards - correct answer ✔✔definitions, procedures or formats agreed upon by an organization
approved for setting standards
international standards organization (ISO) - correct answer ✔✔-model of 7 layers: physical, data link,
network, transport, session, presentation, adn end user application
- ISO 9000: set of 5 universal standards of product quality assurance
health care informatics standards - correct answer ✔✔defines a commonly agreed upon manner of
collecting, maintaining, or transferring data between computer systems
standardization of data elements - correct answer ✔✔1. defining what to collect
2. deciding how to represent what is collected (by designating data types or terminologies)
3. determining how to encode the data for transmission
why are health care data standards needed? - correct answer ✔✔- data for exchanging information
across providers and sending messages/ encoding
- data for reporting: quality improvement or payment
- reduce redundancies
standardization is also needed for - correct answer ✔✔- document architecture (example: discharge
summay)
- clinical templates
- billing
, where did it all begin? - correct answer ✔✔- latin
- nomenclature (recognized, agreed upon terminology)
- taxonomy (structure of relationships, classification of terms)
- ontologies (entities within a doman and relationships among)
classification - correct answer ✔✔an arrangement based on essential characteristics
terminology - correct answer ✔✔terms representing concepts in a field- health problems, observations,
interventions, or outcomes
vocabulary - correct answer ✔✔terms and definitions
codes - correct answer ✔✔letters/ numbers in schema to ID classes and terms in schema to allow
tracking
where are we now? - correct answer ✔✔healthcare organizations track patient outcomes and quality
indicators
tracking requires - correct answer ✔✔- standardized terminologies and templates
- identifcation of quality indicators
- meaningful measures of quality indicators
- linkage to multiple data sources
current challenge - correct answer ✔✔- most EHRs lack uniform templates for tracking linked health
problems, interventions and outcomes
- most data is not entered in standardized templates or using standardized nursing languages
- most RNs are not familiar or resist SNLs
additional challenges - correct answer ✔✔- mapping nursing to other languages is resource intense
- no "one" nursing language across all settings
Language
standard - correct answer ✔✔an agreement to use a govern protocol, term, or other criterion formally
approved by a nationally or internationally recognized professional trace association or governmental
body
standards - correct answer ✔✔definitions, procedures or formats agreed upon by an organization
approved for setting standards
international standards organization (ISO) - correct answer ✔✔-model of 7 layers: physical, data link,
network, transport, session, presentation, adn end user application
- ISO 9000: set of 5 universal standards of product quality assurance
health care informatics standards - correct answer ✔✔defines a commonly agreed upon manner of
collecting, maintaining, or transferring data between computer systems
standardization of data elements - correct answer ✔✔1. defining what to collect
2. deciding how to represent what is collected (by designating data types or terminologies)
3. determining how to encode the data for transmission
why are health care data standards needed? - correct answer ✔✔- data for exchanging information
across providers and sending messages/ encoding
- data for reporting: quality improvement or payment
- reduce redundancies
standardization is also needed for - correct answer ✔✔- document architecture (example: discharge
summay)
- clinical templates
- billing
, where did it all begin? - correct answer ✔✔- latin
- nomenclature (recognized, agreed upon terminology)
- taxonomy (structure of relationships, classification of terms)
- ontologies (entities within a doman and relationships among)
classification - correct answer ✔✔an arrangement based on essential characteristics
terminology - correct answer ✔✔terms representing concepts in a field- health problems, observations,
interventions, or outcomes
vocabulary - correct answer ✔✔terms and definitions
codes - correct answer ✔✔letters/ numbers in schema to ID classes and terms in schema to allow
tracking
where are we now? - correct answer ✔✔healthcare organizations track patient outcomes and quality
indicators
tracking requires - correct answer ✔✔- standardized terminologies and templates
- identifcation of quality indicators
- meaningful measures of quality indicators
- linkage to multiple data sources
current challenge - correct answer ✔✔- most EHRs lack uniform templates for tracking linked health
problems, interventions and outcomes
- most data is not entered in standardized templates or using standardized nursing languages
- most RNs are not familiar or resist SNLs
additional challenges - correct answer ✔✔- mapping nursing to other languages is resource intense
- no "one" nursing language across all settings
