Terminology use in electronic health records: basic principles.
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.
Watkins
Tera J
TJ
Cerner Corporation, Kansas City, MO, USA.
Haskell
Robert E
RE
Lundberg
Cynthia B
CB
Brokel
Jane M
JM
Wilson
Marisa L
ML
Hardiker
Nicholas
N
D057286:Electronic Health Records; D009737:Nursing Records / Q000592:standards*; D009626:Terminology as Topic