Week 3 Discussion: Standardized Terminology and Language in Informatics

For today’s discussion I am going to talk about usability. I selected this topic because I feel like it should be the foundation for any healthcare information system. Usability refers to the ability of a healthcare information system to be utilized by end users to the desired effect, taking into account user satisfaction, effectiveness of the program and efficiency (Hebda, 2019). If users cannot effectively use it, then the whole program is pointless. I am currently working on a transition to EPIC in the outpatient oncology clinic that I work at. As part of the implementation team one of the things I must answer is how usable is this program going to be for us. To answer that question, you must look at several different levels of usability. Is our current computer system going to support this new application? How much time is it going to take for nurses to learn how to document? How dramatically is this going to change our workflows? Will this work for us 5-10 years on down the line with our current level of growth? What type of support are leaders and staff going to have? And most importantly are we going to be able to be as efficient as we are now or is this going to slow down? Will this improve patient care? (Hebda, 2019). I have been through a few program transitions now and I have learned that support during the transition is imperative to its success. This has been proven in more case studies than just my own. A hospital in Indonesia took the opportunity of transitioning from a mostly paper system to electronic documentation and looked specifically at usability during “go life.” Nurses had a general over all appreciation for value electronic documentation can give us, specifically not having to decipher handwriting and more readily available historical records but they also shared some difficulties or barriers they faced. One that rings true to me was lack of support both from the nursing leads and software company (Hariyati, 2020). As both a leader and a role model my intent is to learn as much about the program as possible. My goal during this upcoming transition is to be the on hands support, to be the bridge between the nurses and the EPIC support team. I hope to negate any feelings of lack of support from the staff. After we have gone live I hope to continue to be there for staff and get their feedback on usability of the program and take it back to the EPIC support team.


Hariyati, R.T.S., Hamid, A.Y., Erando, T., & Hasibuan, Z.A. (2020). Usability and satisfaction of using electronic nursing documentation, lesson-learned from new system implementation at a hospital in Indonesia. Internal Journal of Healthcare Management 13(1). P45-52. https://eds-a-ebscohost-com.chamberlainuniversity.idm.oclc.org/eds/pdfviewer/pdfviewer?vid=9&sid=0c6256cb-7737-40d4-ab44-305712a44c4e%40sdc-v-sessmgr01Links to an external site.

Hebda, T., Hunter, K. & Czar, P. (2019). Handbook of Informatics for Nurses & Healthcare Professionals 6th edition. Pearson. New York, NY.

Our Week 3 Lesson teaches us that using proper terminology and capturing nursing’s unique contributions to healthcare is of the upmost importance (Chamberlain, 2020). Nurse leaders have strived to define the profession of nursing and develop a commonality of language that describes practice to ensure that our contribution to care is captured. Using standardized nursing language demonstrates what nurses do and proves that we are essential.

NANDA is internationally used in nursing language to provide a nursing diagnosis; the clinician’s professional clinical judgment about a patient, family, community responses to health issues. According to Doenges, Moorhouse, and Murr (2019), NANDA currently has 235 labels, including definitions, defining characteristics, and related to or risk factors that help a nurse to define a patient’s problem or need. Using NANDA allows us to be uniform, making reimbursement for our service justifiable. Not only does using a standard terminology to determine a patient’s care needs demonstrate our specific role in healthcare, it supports research by comparing care. It helps us to offer continuity of care to our patients. The NANDA proves that our profession is based on theory and a rationalistic model.

In my practice, I refer to the NANDA list daily. The list helps me to develop a care plan. I base all of my interventions and established goals off of the nursing diagnosis I choose. The NANDA also helps me to identify needs the patient may have by triggering my critical thinking skills. Standard terminology builds confidence in my practice in the aspect that it makes me feel confident. By using the list, I don’t question my judgment of diagnosis. It also allows the clinicians on my team to provide individualized care.  It helps make communication effective.   

Working for an insurance plan, standardized language is essential.  When nurses call in asking for authorization for visits, procedures, testing, etc.  documentation should be clear and concise to avoid interruptions in care for the patient.  


Chamberlain University, 2020, Week 3 RN Information Systems in Healthcare, Lesson 3: Standardized Terminology. https://chamberlain.instructure.com/courses/64806/pages/week-3-lesson-standardized-terminology?module_item_id=8795560

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing diagnosis manual: Planning, individualizing, and documenting client care. Philadelphia: F.A Davis Company.

Meaningful Use 

To be useful, data, and information must be available when needed to whom it is needed and in a form that can be analyzed or used was stated by Hebda, Hunter, & Czar  (2019, p.4). Meaningful use plays a very significant role in the healthcare setting. Its role is to help providers have all the useful information on a patient’s medical health record in order to fully provide them the care that is needed. Giddens (2017) mentioned that the mission is to improve health, health care and reduce costs through the use of information and technology (p.458).  Meaningful use was designed to improve quality, safety and efficiency of patient care with the widespread of electronic health records systems. This impacts my practice because the information given or received on hand will help me create a plan of care designed for that specific patient each time I’m giving care. 


Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). New York, NY: Pearson.

Giddens, J. (2017). Concepts for Nursing Practice (2nd ed.). St.Louis, MO: Elsevier 

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