Electronic health records (EHRs) are a cost-saving and environmentally friendly means for documenting patient care and improving patient safety, quality, and evidence-based practice. Standardized clinical classification systems and terminologies are essential ingredients of the EHR. Their selection must be driven by a clear understanding of requirements for their use and application. This article describes the principle uses of clinical information and motives for consistency in practice, and provides a distinction between classification systems and reference terminologies for clinical settings
|Number of pages||6|
|Journal||Urologic nursing : official journal of the American Urological Association Allied|
|Publication status||Published - 2009|
Watkins, T. J., Haskell, R. E., Lundberg, C. B., Brokel, J. M., Wilson, M. L., & Hardiker, N. (2009). Terminology use in electronic health records: basic principles. Urologic nursing : official journal of the American Urological Association Allied, 29(5), 321-326.