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Nursing Informatics Key Terms.
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Nursing Informatics Key Terms.
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Nursing Informatics Key Terms1. a subject that focuses on managing and processing information, usually
within an agency. The department charged with this responsibility may be
called the information technology (IT) department, the IS (Information Ser-
vices) or MIS (Management of Information Services).: Information technology
2. the science of the management of information, generally interpreted to
mean using computers to manage information: Informatics
3. Technology applied in healthcare, generally meant to refer to electronic
records. Sometimes the name of the department that has the responsibility
for the electronic records.: Health Information Technology (HTI)
4. a discrete piece of objective "information." Theoretically it is the plural of
datum, but in common usage data is used to designate both singular and
plural forms of the word.: Data
5. a discrete piece of objective "information." Theoretically it is the plural of
datum, but in common usage data is used to designate both singular and
plural forms of the word.: PITAC
6. The complete record of an individual's healthcare from many sources that
is created and gathered cumulatively from more than one healthcare agency.
What information in it is accessible and to whom is determined by the individ-
ual whose health it records. This term is often erroneously used to mean an
electronic medical record.: Electronic Health Record
7. clinical practice in which decision making is guided by the best research
evidence available, clinical knowledge, and consultation with the patient to
decide the best patient care. Requires information technology skills: Evidence
Based Practice
8. an agreement to use a given protocol, term, or other criterion that has been
formally approved by a nationally or internationally recognized professional,
trade associations or governmental body.: Standard
9. a set of terms with agreed upon definitions useful in a given situation.: Stan-
dardized Terminology
10. the science of managing healthcare information that draws on information
and computer science, healthcare discipline knowledge, and theories such as
socio-technical theory, change theories, cognitive theory, usability principles,
learning theories and chaos theory.: Healthcare Informatics
11. the use of data or documents that have been collected for another purpose,
such as data in a medical record, for other purposes. An example would be dis-
covering how many patients with a given condition have a specific treatment.
In the EHR world it refers to healthcare data collected for patient care, then
being deidentified and used in research. For more information.: Secondary
Data
, Nursing Informatics Key Terms
12. data that represents the same piece of data for many different records e.g.
a list of surgeries and length of stay for all patients for the month of April.
The purpose for studying data in the aggregate is to determine patterns. The
data may be from any size database from just a few records to millions of
records.: Aggregated Data
13. part of an information system that correlates information from many dif-
ferent sources including specific patient data and the literature to provide
suggestions to the clinician. It may be a spreadsheets on which a user creates
a model to use and specially designed decision tools that assist the user to
structure the problem and make a decision based on a weighted analysis of
the analysis. See Clinical Decision Support System.: Decision Support Systems
14. An independent group that serves as adviser to the nation to improve
health. Under the charter of the National Academy of Sciences this group pro-
vides independent, objective, evidence-based advice to policymakers, health
professionals, the private sector, and the public.: IOM (Institute of Medicine)
15. see article by Hedba and Calderone.This group developed competencies
in various areas. See TIGER Informatics competencies.: Technology Informatics
Guiding Educational Reform
16. a 3-phase initiative funded by the Robert Wood Johnson Foundation ,
2010.: Quality and Safety Education for Nurses
17. Although the term says physician, it includes nurse practitioners with pre-
scriptive authority. It describes the use of the computer to enter prescriptions.
These systems should be able to catch not only errors in prescribing, but also
problems with drug interactions or allergies that could present a problem. In
short, a well designed CPOE should be a decision support system for clini-
cians who prescribe medications. It will not make decisions for the clinician,
but present difficulties, if any, that it sees with a given order.: Computerized
Provider order Entry
18. a multi-disciplinary medical record that is organized by the client's prob-
lems with all disciplines charting in the same place for each problem. Most
patient records today are organized by discipline: Problem Oriented medical
record
19. a computer system devised by Dr. Larry Weed and associates at the Univer-
sity of Vermont in the late 1960's and early 1970's. Problem Oriented Medical
Information System: PROMIS
20. an agreed upon format for a procedure. In computer terminology it of-
ten refers to methods for exchanging data between two devices. It includes
standards for the type of error checking, data compression if used, how the
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