Ch. 15 Yoost

Computerized Decision Support Systems (DSSs)

Systems that provide safe practice alerts and reminders to improve quality of care and assist in diagnosis and medication.

Clinical Decision Support Systems (CDSSs)

A type of DSS that pairs with computerized provider order entry to suggest dosages, check for allergies, and propose lab tests.

Computerized Provider Order Entry (CPOE)

A system allowing healthcare orders to be directly communicated to relevant departments, reducing transcription errors.

Agency for Healthcare Research and Quality (AHRQ)

An organization that recommends safe practices like CPOE to enhance healthcare quality.

Electronic Medical Record (EMR)

Documentation of a single episode of care, part of the broader Electronic Health Record (EHR).

Electronic Health Record (EHR)

A longitudinal record of a patient's health history and care over time.

Nursing Minimum Data Set (NMDS)

A standardized collection of essential nursing data to document nursing diagnoses, care, and outcomes.

SNOMED CT

A standardized coding system designed to capture detailed information about a patient’s medical history and outcomes.

Standardized Nursing Terminology

Terminology that enables consistent data collection and improves visibility and documentation of nursing practice.

International Council of Nurses (ICN)

An organization that provides standardized nursing diagnostics and terminologies.

NANDA International (NANDA-I)

An organization that develops and maintains a standardized nursing diagnoses taxonomy.

Nursing Outcomes Classifications (NOCs)

A system providing standardized, measurable patient outcomes.

Nursing Interventions Classifications (NICs)

A system that provides standardized nursing interventions.

Legibility and Availability of Documentation

Improved provider communication due to easier reading and access to patient documentation.

Workflow Issues in CPOE

Challenges such as provider resistance and nonstandard terminology that can hinder the effectiveness of computerized systems.

Computerized Medication Profiles

Records that store patients' medication information within EHRs.

Evidence-Based Practice Initiatives

Health care practices that are informed by the best available evidence to improve patient outcomes.

Patient Safety at Risk

The consequence of ignoring alerts in clinical decision support systems due to alert fatigue.

Standardized Outcomes

Outcomes defined in a consistent manner across various settings to measure the effectiveness of care.

Remote Access to Patient Information

Allows multiple providers to access a patient's health records simultaneously for efficient care.

Perioperative Nursing Data Set (PNDS)

Terminology standardized for use by perioperative nurses.

Nursing Management Minimum Data Set (NMMDS)

Data set used by nurse managers for effective data collection and management.

Controlled Vocabulary

A defined system of terms used to standardize communication within a field.

Multidisciplinary Terminologies

Terminologies that facilitate understanding among different health care professions.

Patient Information Availability

Supports timely and effective health care delivery through access to electronic records.

Standardization Impact on Patient Outcomes

The positive effect achieved through implementing consistent terminology in nursing practices.

Quality Improvement in Nursing

Enhancement of patient care quality facilitated by standardized nursing documentation.

Evidence-Based Nursing Data

Data that is comparable and sharable, derived from scientific research to support nursing practices.

Decision-Making Support in Nursing

Information provided by standardized terminology that aids in care and policy formation.

World Health Organization Family of International Classifications (WHO-FIC)

An accepted classification system that includes standardized terminologies like ICNP.

Pharmacological Alerts

CDSS features that warn about potential drug allergies and drug-drug interactions.

Timely Access to Diagnostic Test Results

An EHR feature allowing quick interpretation and response to a patient's medical needs.

Patient-Centered Care

Care that respects and responds to individual patient preferences, needs, and values.

Interprofessional Communication

Communication and collaboration among different health professionals to improve patient care.