Modern Clinical Medicine Research

Download PDF (210.7 KB) PP. 13 - 19 Pub. Date: April 13, 2017

DOI: 10.22606/mcmr.2017.11003

• Randy J-C Huard^*
  St. Cloud State University, Department of Nursing Science, School of Health and Human Services, St. Cloud, Minnesota, United States
• Karen A. Monsen
  University of Minnesota of Minnesota, School of Nursing, Minneapolis, Minnesota, United States

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.

Standardized nursing terminology; electronic health record; interoperability; Omaha
System; SNOMED CT

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