Standardized Terminologies

“Standardized terminologies is commonly-understood set of terms used to describe clinical judgements involved in assessments (nursing diagnoses), along with the interventions, and outcomes related to the documentation of nursing care.”(NANDA International, Inc.) For a nurse to be able to provide care, sustain life, ensure recovery, alleviate suffering and promote health, it should be documented within the electronic health record (EHR). When capturing such informations within the EHR, information must be shared between healthcare professionals and the health care team. When it comes to sharing information between healthcare professionals and the healthcare team, these informations must be recorded and documented in a standardized form. There are several different terminologies used in nursing, each developed for a variety of care settings. It can be difficulty when choosing which terminology to use for different situations/scenarios, but it is important to use standard terminology to have provide better care and to have improved patient outcomes. The use of standardized terminologies is to ensure that nurses accurately document patient assessments, patient care, interventions, and outcomes. There are many benefits when it comes …show more content…
The purpose of using standardized terminologies is for the healthcare team to better provide the care patients need and deserve. It is to ensure that the healthcare team maintains safety and to prevent miscommunication/misunderstandings. Effective communication regarding care plan of a patient through the use of an EHR and standard terminology will lead to improved continuity, safe care, and achievement of desired patient outcomes. Nurses and the healthcare team can achieve their goals with the incorporation of standardized nursing terminology within electronic health