Nursing Informatics: Care Delivery Application

Flashcards based on key concepts from the Nursing Informatics lecture notes.

Clinical Information System (CIS)

A system designed to support care by providing instant access to information for clinicians.

LOINC

Logical Observation Identifiers Names and Codes; a code system for all units of measures used in international science, engineering, and business.

UCUM

The Unified Codes for Units of Measurement that often represent the 'answer' for a test to the LOINC 'question' code.

SNOMED CT

Systematized Nomenclature of Medicine-Clinical Terms; provides normalized names for clinical drugs.

RxNorm

A unified language of radiology terms for standardized indexing and retrieval of radiology information resources.

ICD-10

The 10th revision of the International Statistical Classification of Diseases maintained by the World Health Organization.

CPT®

Current Procedural Terminology; a set of codes used to bill outpatient and office procedures.

NDC

National Drug Code; a list maintained by the FDA of all drugs manufactured or processed for commercial distribution.

HITECH Act of 2009

Health Information Technology for Economic and Clinical Health Act aimed at promoting the adoption of health information technology.

Drummond Group

An organization that provides high-level testing services for healthcare software developers.

CCHIT

Certification Commission for Health Information Technology; a non-profit group focused on advancing health information technology.

Electronic Health Record (EHR)

A digital version of a patient’s paper chart, designed to improve the quality of care.

Decision Support

The use of computer reminders and alerts to improve diagnosis and patient care.

Patient Support

Encompasses tools for patient education, home telemonitoring, and telehealth.

Reporting and Population Health Management

Data collection tools to support public and private reporting requirements.

Advantages of Electronic Health Records

Increased delivery of guidelines-based care, enhanced monitoring for disease conditions, and reduced medication errors.

Ownership of EHRs

The sense of engagement clinicians have towards the selection, implementation, evaluation, and optimization of the EHR.

Implementation Planning

Planning that occurs alongside EHR vendor selection to measure the success of EHR.