Standardized Nursing Terminology Use in Electronic Health Records in Minnesota

Abstract

Abstract. The extent to which standardized nursing terminologies are used in electronic health records (EHRs) is not known. The goal of this project was to identify standardized nursing terminologies in use in Minnesota EHRs. Graduate nursing students with guidance from the Minnesota Department of Health eHealth Initiative surveyed representatives of 360 healthcare systems and organizations throughout the state. Entities included clinics, hospitals, long-term care facilities, public health agencies, group homes, and the state prison system. Results show that 92% of these healthcare entities utilized EHRs; however only 30% of entities used a standardized nursing terminology within their EHR; and of these, the Omaha System (80.5%) and SNOMED CT (6.5%) were most frequent. Analysis of respondent comments showed a general lack of awareness regarding standardized nursing terminologies and the importance of using them to document nursing interventions, assessments, outcomes, continuity of care, and research.