Terminology use in electronic health records: basic principles

Tera J Watkins, Robert E Haskell, Cynthia B Lundberg, Jane M Brokel, Marisa L Wilson, Nicholas Hardiker

Research output: Contribution to journalArticle

13 Citations (Scopus)

Abstract

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
Original languageEnglish
Pages (from-to)321-326
Number of pages6
JournalUrologic nursing : official journal of the American Urological Association Allied
Volume29
Issue number5
Publication statusPublished - 2009
Externally publishedYes

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