Today healthcare environment is characterized by significant emphasis on establishing the EHR in all settings. Data sets are compromised of data elements brought together for a specific reason. When values are assigned to the elements in a data set, the resulting data are most often stored in a database. Modern databases are used for storing data in a way that maintains the logical relationships among data elements and are stored in a computer. In healthcare and nursing, there are different types of databases, including bibliographic, payment claims, research, and the clients record. Any clients health record whether paper-based or computer-based, is a database made up of myriad data elements for which data are gathered and used in health and healthcare decision-making by healthcare practitioners, providers, individual and family.

The concept of the EHR emerged, initially, as a computer-based patient record or CPR and was given a significant impetus by a 1991 from institute of medicine that advocate the adaption of CPR as the primary source of client healthcare data and information. In this seminal work the CPR was conceived as a longitudinal medical record receiving data from multiple worldwide source. Other terms for the CPR has been used, such as electronic medical record(EMR), electronic patient record(EPR), computerized medical record(CMR). American society for testing and materials( ASTM) standard defines the EHR as any information related to the past, present, future physical/mental health, or condition of an individual. The information resides in electronic system used to capture, transmit, receive, store, retrieve, link, and manipulate multimedia data for the primary purpose of providing health and healthcare related services. An EHR encompasses the entire scope of health information in all media forms. In 2001, the national committee on vital health statistics(NCVHS) identified the patients medical record information(PMRI) as a model of the specific content necessary for the EHR, a component of the national health information infrastructure(NHII ).

The healthcare provider dimensions promote quality patient care, access to compete the accurate patient data 24 hours per day/days per week, and includes provider notes, clinical orders decision support programs, and practice guidelines. This information helps stakeholders identify and track health threats, assess population health, create and monitor programs and services and conduct research. Informatics nurses serve an important role in designing, developing, implementing, monitoring, evaluating and modifying EHR’s, so these records facilitates nurses work, growth of the discipline, and health service research.

TERMINOLOGIES: Why are informatics nurses and nurse scholars so interested in terminologies? Nursing terminologies focus on the patient and care process, not reimbursement or mortality, and are increasingly important as EHR’s become an integral component of healthcare service delivery. Data elements are terms on which data are collected and for which values are assigned. A specific, purposeful group of data elements, representing subset of concepts within a discipline, is a data. Nursing minimum data set(NMDS) developed through Dr. Harriet Werley’s research is considered the foundational work for nursing languages and represents the first attempt to standardize the collection of essential nursing data. This data set contains 16 data elements divided into patient, service, and nursing care elements, and foster the comparison of nursing data across time, setting, and population. The four nursing care elements includes nursing diagnosis, nursing intervention, nursing outcome, and intensity of nursing care. There are other data sets that contains nursing data elements, such as the minimum data set(MDS) developed for long term care facilities, and outcome and the home health data set that is used by home health agencies.

NANDA: NANDA-I has evolved from an alphabetical listing in mid-1980’s to a conceptual system that guides the classification of nursing diagnosis in a taxonomy and includes definitions and defining characteristics. NURSING INTERVENTIONS CLASSIFICATION(NIC): The four edition of NIC contains 514 nursing interventions that described the treatments nurses perform, update linkage with NANDA diagnoses, and core interventions identified for 44 specialty practice areas.

CLINICAL CARE CLASSIFICATION(CCC)/HOME HEALTHCARE CLASSIFICATION(HHCC): The CCC system is a research-based designed to standardize the terminologies for documenting nursing care in all clinical care settings. OMAHA SYSTEM: The most recent revision of the Omaha system was released in November Originally developed to use in home health practice, the Omaha system is used in all clinical settings. PERIOPERATIVE NURSING DATA SET(PNDS): The PNDS provides a universal language for perioperative nursing practice and education and a framework to standardize dovumentation.

SNOMED CT: The SNOMED CT is a core clinical terminology containing healthcare concepts with unique meaning and formal logic-based definitions organized into multiple hierarchies. ABC CODES: The ABC codes provides a mechanism for coding integrative health interventions by clinician by state location for administrative billing and insurance claims. PATIENT CARE DATA SET(PCDS): The PCDS includes terms and codes for patient problems, therapeutic goals, and patient care orders.

LOGICAL OBSERVATION IDENTIFIERS NAME AND CODES(LOINC): The LOINC is originated as a database of standardized laboratory terms for results reporting for chemistry, hematology, serology, microbiology, and toxicology. INTERNATIONAL CLASSIFICATION FOR NURSING PRACTICE(ICNP): The ICNP is a combinatorial terminology for nursing practice developed by the international nursing community under sponsorship of the international council of nurses(ICN). NURSING MANAGEMENT MINIMUM DATA SET(NMMDS): The NMMDS includes terms to describe the context and environment of nursing practice, and includes terms for nursing delivery unit/service, patient/client population care delivery method, personnel characteristics, and financial resources.

ORGANIZATION AS RESOURCES: Many organizations have emerged to provide information resources and value-added membership benefits that support those individuals interested in healthcare and nursing informatics. AMERICAN MEDICAL INFORMATICS ASSOCIATION: The AMIA is an individual membership organization dedicated to the development and application of medical informatics in the support of patient care, teaching, research, and healthcare administration. AMIA serves as an authoritative body in the field of medical informatics and frequently represents the United States in the informational area of medical informatics in international forums and is the U.S member of the International Medical Informatics Association (IMIA). The Nursing Informatics Workgroup (NI-WG) has long been the most active AMIA workgroup and has established several competitive scholarship.

HEALTHCARE INFORMATION AND MANAGEMENT SYSTEM SOCIETY The HIMSS represents membership individuals and corporations interested in healthcare informatics, clinical system, information system, management engineering and telecommunications. HIMSS has special interest groups, local and state chapters, a fellows recognition programs, and the recently established professional credentialing service offering four certifications. NATIONAL LEAGUE FOR NURSING The mission of (NI.N) is to advance the quality nursing education that prepares the nursing workforce to meet the needs of diverse population in an ever-changing healthcare environment. The ETIMAC was established to promote the effective use of technology in the nursing education, both as a teaching tool and as an outcome for student and faculty learning and to advance the integration of information management into educational practices and program outcomes. The NLN also address faculty development and educational research.

SOCIETY FOR HEALTH SYSTEM The SHS is a society of the institute of industrial engineering. This organization exist to enhance the career development and to continue education of professionals who use industrial and management engineering expertise for productivity and quality improvement in the healthcare industry. ASSOCIATION FOR COMPUTING MACHINERY The ACM is a major force in advancing the skills of information technology professionals and students worldwide. ARMA INTERNATIONAL ARMA International is a not-for-profit association serving information management professionals in the U.S, Canada and other nations. Its mission is to provide education, research, and networking opportunities to information professionals, to enable them to use skill and experiences.

AMERICAN SOCIETY FOR INFORMATION SCIENCE AND TECHNOLOGY The ASIS & T describes itself as the society for information professionals leading the search for new and better theories, techniques and technologies to improve access to information. The explosion of the World Wide Web now makes those diverse resources continuously available from any world location.

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