A nurse is documenting in a patient's electronic health record and enters the common phrases such as blood pressure, intact skin incision, and active bowel sounds. The system translates these common phrases into data that the computer can use. This activity reflects use of a:
A) Minimum data set.
B) Reference terminology.
C) Interface terminology.
D) Classification.

Question

Quizplus · Accepted Answer

Interface terminology allows for the translation of common clinical phrases into structured data that computers can understand and use, facilitating effective documentation and data retrieval in electronic health records.

A Nurse Is Documenting in a Patient's Electronic Health Record