Running head: STANDARDIZED NURSING TERMINOLOGY

Standardized Nursing Terminology Assignment

Samantha J. Hasenzahl
Bon Secours Memorial College of Nursing

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Standardized Nursing Terminology Assignment
In 2004, the Department of Health and Human Services released The Decade of Health
Information Technology: Delivering Consumer-centric and Information-rich Health Care that
mandated a National Health Information Network. The purpose of this network was to use
information technology to connect electronic medical records from various healthcare settings,
disciplines, locations, and information systems. The ability for different healthcare providers to
share data would help reduce medial errors, improve care, and save money (Westra, Delaney,
Konicek, & Keenan, 2008).
In order for this type of system to work there needed to be some standardizations, or
agreed-upon ways to record and exchange data within and across information systems (Westra
et al, 2008, p. 258). Standardized terminologies organize and sort various concepts and aspects of
healthcare (i.e. nursing diagnoses, interventions, and outcomes) that allows for easier
communication and understanding between various healthcare professionals. Although this
legislation is fairly new, the importance of standardized terminology has been around for a long
time. The International Classification of Diseases was developed in the 1850s to help classify
causes of death. The North American Nursing Diagnoses Association (NANDA) created the first
standardized nursing diagnoses in 1975 with the Omaha project. Later on NANDA developed the
Nursing Interventions Classification (NIC) and the Nursing Outcomes Classifications (NOC)
(Westra et al, 2008). NIC and NOC allow for nurses to document their care in a format that
allows future nurses to better understand their patients prior medical history and care.
The Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT) was
developed to provide standardized terminology to the health profession community. SNOMED
CT is a thorough list of clinical terms that are organized and categorized in such a way that it

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improves the documentation, retrieval, and distribution of health information (Rafiei,
Pieczkiewicz, Khairat, Westra, & Adams, 2014). In other words, it connects concepts that make
the documentation and retrieval of health information easier which improves quality of care.
Advantages
The ultimate goal for health IT and standardized terminology is to improve the quality of
care. Cost reduction, decreased pharmacological and medical errors, increased efficacy, and
improved communication are just a few of the advantages of standardized terminology.
Communication can be improved because documentation will be standardized, in other words
there is a universal language (Sweeney, 2010, p. 535) that provides consistency to
documentation and evaluation of patient care.
In addition, standardized terminology makes the conduction of research easier. When
concepts and terms are standardized a researcher only has to look up a common phrase or word
to find a lot of subjects. Prior to standardized terms/concepts such as interventions, diagnoses,
and signs and symptoms may not have been as easily found. Linking those concepts
(intervention to symptoms to evaluation) has also been made easier through standardization. The
common index of terms has made it easier to obtain larger sample sizes, which in turn allows for
more valid data. As a result, more evidence based practice has been produced and this leads to
improved quality of care.
Disadvantages
Having a standardized system has many advantages; however, as with every system there
are some disadvantages as well. With the increase in accessibility to technology and information
research has boomed; although this is a positive, with all the new information being discovered
each and every day it is hard to keep up. Not everything can be included in the standardized

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terminology list. Just as Websters Dictionary cannot keep up with todays slang, developing
code for new terminology takes time. DeBlieck, LaFlamme, Rivard, and Monsen (2013)
reviewed several electronic health records (EHRs) and found a dearth of standardized
documentation and clinical decision support related to postoperative nausea and vomiting/postdischarge nausea and vomiting (PONV/PDNV) guidelines and lack of measureable interventions
and outcomes specific to PONV/PDNV (p. 375). PONV/PDNV are common side effects of
anesthesia, yet there is limited standardization around the recognition of and interventions for
this problem.
There is not a centralized system that is used throughout the country, let alone the world.
This disconnect between various systems can make it difficult for health professionals to access
patient information and history (Sweeney, 2010). Just like with paper charts, faxes are still
required in order to transfer records. This could potentially result in a HIPPA violation. Just like
developing a standardized terminology, developing a centralized, standardized EHR is
imperative in ensuring quality patient care.
Another limitation to standardized terminologies and EHR is that a lot of systems are
based on the medical model. They are not necessarily based on nursing terminology or the
nursing process. Given that the terminology is based on the medical model, some nurses may not
find the systems to be relevant to the care their practice and the care they are providing
(Sweeney, 2010).
Why Standardized Nursing is Important
Having standardized terminology is logical, but a single agreed upon model of
terminology is imperative for practical use. The Systematized Nomenclature of MedicineClinical Terminology (SNOMED-CT) is becoming this agreed up model. SNOMED-CT allows

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for clinicians to use terms that fit their practice and share data across systems without reentry of
data (Westra et al, 2008, p. 261). In other words, SNOMED-CT allows doctors and nurses from
New York to understand the care that a patient received in Los Angeles. In addition, standardized
terminology makes research projects easier which in turn improves clinical care as nurses are
able to use evidenced-based practices.

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References
DeBLIECK, C., LaFLAMME, A. F., Rivard, M. J., & Monsen, K. A. (2013). Standardizing
Documentation for Postoperative Nausea and Vomiting in the Electronic Health
Record. AORN Journal, 98(4), 370-380. doi:10.1016/j.aorn.2012.12.021
Rafiei, M., Pieczkiewicz, D., Khairat, S., Westra, B.L., & Adams, T. (2014). Systemized
nomenclature for the structured expression of perioperative medication management
recommendations. American Journal of Health-Systems Pharmacy, 71(23), 2020-2027.
doi: 10.2146/ajhp130593
Sweeney, P. (2010). The effects of information technology on perioperative nursing. AORN
Journal, 92(5), 528-540. doi:10.1016/j.aorn.2010.02.016
Westra, B.L., Delaney, C.W., Konicek, D., & Keenan, G. (2008). Nursing standards to support
the electronic health record. Nursing Outlook, 56(5), 258-266.
doi:10.1016/j.outlook.2008.06.005