A new nurse is confused by the terminology used by the electronic health record (EHR). When the nurse complains to the precepting nurse, the best explanation by the preceptor is that this occurs because
a. many systems interact with each other and need a standardized language.
b. nursing is not the only discipline to use the EHR, so wording reflects this.
c. terminology used by the EHR is driven by financial reimbursement needs.
d. the system was designed by people in computer and information sciences.
A
The EHR uses different interconnecting modules, so it is imperative that terminology used in each is standardized. This allows for seamless patient care delivery.
It is true that nursing is not the only discipline to use the EHR, but it is not the disciplines themselves that use different vocabularies; it is the system each discipline uses that creates the need for a standardized vocabulary.
Needs of the financial departments are considered when developing EHRs, but this is not the only consideration.
The information technology side of EHR development allows for standardization of terminology among disciplines. This is not the most inclusive answer.
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