Standardized Terminology – Why is it Important?

Standardized Terminology – Why is it Important?

Agencies are rushing to adopt EHRs to meet rapidly evolving federal, state, local, program, and grant mandates regarding electronic documentation.

In researching software options, you will find a key difference among them:

  • Some are based on standardized terminologies while others are not

Read our recent articles which discuss what does standardized terminology in healthcare really mean, and what criteria should a standardized terminology meet.

If your program goals include the ability to measure client outcomes to clinician interventions in a reliable and valid way, you should consider purchasing software based on a standardized terminology.

A standardized terminology is simply a common language, nomenclature, classification, or taxonomy designed to be shared among users.

In health care settings, use of standardized terminologies is essential to clearly and accurately document client assessments, care, and outcomes.

If you cannot describe your care to others using a commonly understood language, then you cannot effectively:

  • Establish standards
  • Influence policy
  • Expect funding for your programs

There are many benefits to using a standardized terminology, including:

  • Meeting mandated interoperability requirements and standards
  • Facilitating communication among nurses and other health care workers
  • Enabling the collection of shared data to improve health care at the local level and beyond
  • Adhering  to standards of care and best practices, especially with the concurrent use of shared pathways
  • Evaluating the effectiveness of community health care at all levels through measurement of outcomes
  • Giving better visibility to your work

One example of an internationally-used standardized terminology is the Omaha System.

This standardized terminology is a leader among its peers in meeting the stringent criteria necessary for full integration and interoperability in electronic health records.

One of the first clinical nomenclatures to be developed, the Omaha System is a research-based and provides interoperability and communication across the continuum of community health: health clinicians, administrators, educators, and researchers.

The Omaha System is composed of three essential components to describe care:

  1. The Problem Classification Scheme (assessment)
  2. The Intervention Scheme (interventions/clinician actions)
  3. The Problem Rating Scale for Outcomes (measurement of outcomes).

You can read more about the Omaha System at You will find a valuable overview of the system, publications, FAQ’s, case studies, references, links, conferences, and the Omaha System Listserv.


Now you know more about Standardized Terminology, why not Contact Us at (507) 388-4141 to tell us what you need your EHR software to do. Nightingale Notes might be just what you’re looking for.

Download our eBook, “Standardized Terminology for EHRs” to learn more about what criteria standardized terminology should meet so that you know what to look for when choosing a standardized terminology for your EHR.

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Check out the references below for even more information about standardized terminologies and Omaha System users! You can also download our free ebook, Evaluating Standardized Terminology in EHR: Communicating What You Do.


By | 2018-03-15T10:20:37+00:00 March 6th, 2012|Standardized Terminology|0 Comments

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