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Nursing Informatics - Glossary Terms
Terms in this set (29)
Standardized Nomenclature of Medicine Clinical Terms (SNOMED CT)
A systematically organized, computer processable collection of clinical terms providing codes, terms, synonyms, and definitions covering diseases, findings, procedures, microorganisms, substances, etc. It allows a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care.
Standardized Clinical Terminology
Terminology required directly or indirectly to describe health conditions (e.g. symptoms, complaints, illness, diseases, disorders, etc.), and healthcare activities. Used in medical records, clinical communication, and medical science.
Standardized Nursing Data
A uniform collection of nursing data from the patient record, which may include nursing diagnosis, interventions, outcomes, and the intensity of nursing care.
Standardized Nursing Terminology
A classification system that allows for the standardized collection of essential nursing data. The collected data are meant to provide an accurate description of the nursing process used when providing nursing care. This allows for the analysis and comparison of nursing data across populations, settings, geographic areas, and time.
Have their origins in the
(a) design and development
(b) implementation and customization of a technology
(c) interactions between the operation of a new technology and the new work processes that arise from a technology's use.
The use of information and communication technologies to deliver care by distance
Health professionals deliver care from a different location than the patient using information and communication technologies.
Information and Communication Technologies (ICTs)
Technologies that facilitate communication and the management, processing, and transmission of information by electronic means. For health refer to the interaction between patients and health service providers, institution-to-institution transmission of data, or peer-to-peer communication between patients and/or health professionals.
- EX. health information networks, electronic health records, telemedicine services, wearable and portable systems that communicate, health portals, and many other technology-based tools assisting disease prevention, diagnosis, treatment, health monitoring, and lifestyle management.
The ability to seek out information when there is a need, find high quality sources, and apply them appropriately.
International Classifications of Nursing Practice (ICNP)
A unified nursing language system. It is a compositional terminology for nursing practice that facilitates the development of, and cross-mapping among, local terms and existing terminologies.
The ability of two or more systems or components to exchange information and to use the information that has been exchanged.
Standards for the exchange, integration, sharing, and retrieval of electronic health information in a consistent manner to support clinical practice and the management, delivery, and evaluation of health services.
The use of wireless tools to deliver and access virtual care and/ or health information.
A science and practice [which] integrates nursing, its information and knowledge, and their management, with information and communication technologies to promote the health of people, families and communities worldwide (IMIA-NI, 2009).
Personal Health Record (PHR)
A complete or partial health record under the custodianship of a person(s) (e.g. a patient or family member) that holds all or a portion of the relevant health information about that person over their lifetime
The right of individuals to determine how, when, to whom and for what purposes any personal information will be divulged.
Occurs when there is "unauthorized access to or collection, use, or disclosure of personal information". Such activity is "unauthorized" if it occurs in contravention of applicable privacy legislation, such as PIPEDA, or similar provincial privacy legislation. Commonly happen when personal information of customers, patients, clients, or employees is stolen, lost, or mistakenly disclosed.
In the health context refers to "a health information custodian shall take steps that are reasonable in the circumstances to ensure that personal health information in the custodian's custody or control is protected against theft, loss and unauthorized use or disclosure and to ensure that the records containing the information are protected against unauthorized copying, modification or disposal" (Office of the Privacy Commissioner, 2011).
Canadian Health Outcomes for Better Information and Care (C-HOBIC)
An initiative to introduce systematic, structured language to admission and discharge assessments of patients receiving acute care, complex continuing care, long-term care, or home care. This language can be abstracted into local and provincial databases or EHRs.
Decision at which a nurse arrives following a process of observation, reflection, and analysis of observable or available information or data.
Clinical Information System (CIS)
General term often used interchangeably to describe a computerized clinical application, electronic health record system, or departmental clinical system (e.g. laboratory information system).
A complex know-act based on combining and mobilizing internal resources (knowledge, skills, attitudes) and external resources to apply appropriately to specific types of situations.
Decision Support Tools
Tools used for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery.
Electronic Health Record (EHR)
The systems that make up the secure and private lifetime record of a person's health and health care history. These systems store and share such information as lab results, medication profiles, key clinical reports (e.g. hospital discharge summaries), diagnostic images (e.g. X-rays), and immunization history. The information is available electronically to authorized health care providers.
Electronic Medical Record (EMR)
A computerized record of care that clinicians maintain on all clients who receive care within a specific setting (e.g. primary care, hospital, home care agency). The record details patient demographics, clinical encounters, medical and drug history, referrals, consults, and diagnostic information such as laboratory and imaging results. It is often integrated with other software that manages activities such as billing and scheduling.
A continuous interactive process involving the explicit, conscientious, and judicious consideration of the best available evidence to provide care in nursing practice.
Health Information Systems (HIS)
A combination of vital and health statistical data from multiple sources, used to derive information and make decisions about the health needs, health resources, costs, use, and outcome of health care.
The ability to access, understand, and act on information for health. Health professionals, such as nurses, play a key role in developing these skills by providing clear and accurate information to clients (Health Literacy Council of Canada, 2011).
Assessable and observable manifestations of the critical learnings needed to develop the competency.
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