1. Developing Standardize d Terminologie s in Nursing Informatics Jessah Mae G. Alicaway, R.N.

2. STANDARDIZED NURSING TERMINOLOGIES  is a nursing terminology that is in some way approved by an appropriate authority or by general consent

3. Why Do We Need Standardization?  Improve communication  Support evidenced-based practice  Improve standardization of care  Enable decision support

4. American Nurses Association (ANA)  which operates a process of de jure standardization through its Committee For Nursing Practice Information Infrastructure (CNPII) (http://www.nursingworld.org/npii/)

5. 7 ACTIVE NURSING TERMINOLIGIES

6.  CCC (Clinical care classification)  ICNP (International classification of nursing practice)  NANDA-I (North American Nursing Diagnosis Association International )  NIC (Nursing intervention classification)

7.  NOC (Nursing outcomes classification)  Omaha Home Health Care system  PNDS (Perioperative nursing data set)

8. 3 MULTIDISCIPLINARY TERMINOLOGIES

9.  ABC (Alternative Billing Codes )  LOINC (Logical Observation Identifiers Names And Codes)  SNOMED CT (Systematic Nomenclature Of Medicine Clinical Terms)

10. DATA ELEMENT SETS  NMDS (Nursing Minimum Data Set)  NMMDS (Nursing Management Minimum Data Set)

11. Standardizing Terminology in the EHR  improves documentation quality & integrity  facilitates data retrieval – research – clinical use  provides understandable documentation  lowers operating costs

12.  eliminates the need for manual searching of records  eliminates documentation redundancy  decreases processing errors  can decrease documentation time  improves billing  promotes perception of increased quality of care

13. Why Haven't We Done It?  Lack of industry standards regarding language (systems are not intra-operable)  Standardized language adoption is required within professions and across regions and countries-who’s in charge?  Standardized and widespread education is needed

14.  Unique universal patient identifiers are required to access patient info  Security/privacy/confidentiality

15. Recommendations  Ongoing training programs are needed for current & future classification systems  Get involved in standards organizations  Contribute to and take ownership for the creation and maintenance of a comprehensive language  Assume responsibility for clinical vocabulary implementation & maintenance within health care organizations

16. Developing Standardized Terminologies in Nursing Informatics Jessah Mae G. Alicaway, R.N.