Steps in Implementing Standardized Nursing Languages

 

William Goossen in a post to the  ni-wg@lists.amia.org on July 23, 2013 suggested the following nine stages of implementing  and using a standardized nursing terminology.

(NT = nursing terminology, EHR = electronic health record)

Stage 0 no nursing terminology (NT)

Stage 1 NT used in paper record

Stage 2 NT in structured electronic format

Stage 3 NT implemented in a single EHR for daily documentation

Stage 4 NT used from 3 to obtain data for analysis

Stage 5 NT used in a EHR or message standard

Stage 6 NT modeled in standard information models

Stage 7 NT with standard information models deployed across multiple vendor systems for continuity of care and/or reporting.

Stage 8 NT in information model collected from multiple sites and multiple vendor systems and used for collaborative analysis and research. Could support nursing minimum data set deployment on state and national levels from records instead of from separate study forms.

Stage 9. Same as 8 on international level. Would allow retrieval from EHRs in different countries based on NT and data models and could facilitate deployment of the International NMDS.

Created July 2, 2014