NI-BC key terms

The interdisciplinary practice of collecting, managing, and using information, often with technology, to support decision-making and solve problems in a specific field such as nursing or health care.

A specialty that blends nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice, supporting nurses, patients, and care teams.

A framework describing how raw data are processed into information, organized into knowledge, and applied with judgment as wisdom to guide action and decisions.

An abbreviation for Data, Information, Knowledge, and Wisdom that explains how discrete facts gain meaning and context as they move through successive stages toward informed judgment.

A conceptual framework viewing an organization or information system as interrelated parts that take inputs, transform them through processes, and produce outputs while interacting with their environment.

An approach recognizing that technology and the social system of people, roles, and culture must be jointly designed and optimized for an information system to succeed.

A structured set of methods for guiding people through transitions when new processes or technologies are introduced, addressing communication, training, resistance, and adoption.

A digital, longitudinal record of a patient's health information shared across care settings that supports clinical documentation, orders, results review, and decision-making.

A system feature that lets clinicians enter orders such as medications, labs, and imaging electronically, replacing handwritten orders and reducing transcription errors.

Tools embedded in health information systems, such as alerts, reminders, order sets, and reference information, that give clinicians knowledge to support decisions at the point of care.

The electronic sharing of patient health information among separate organizations and systems, enabling care teams to access records across settings and improve continuity of care.

The ability of different information systems to exchange data and correctly interpret and use the shared information without special effort from users.

Health Level Seven Fast Healthcare Interoperability Resources, a standards framework using modular resources and modern web technologies to exchange health data between systems.

A point-of-care technology where nurses scan the patient wristband and medication barcode to verify the right patient, drug, dose, route, and time before administration.

The degree to which a system is effective, efficient, and satisfying for specified users to accomplish their goals in a particular context of use.

The study of how people interact with systems, tools, and environments, applied to design technology and workflows that fit human capabilities and reduce error.

The policies, roles, and processes that define who is accountable for data quality, access, security, and use across an organization.

The degree to which data are accurate, complete, timely, consistent, and relevant for their intended use in care, reporting, or research.

The process of checking data against defined rules, ranges, or formats to detect and correct errors before the data are used or stored.

Information stored in defined, coded fields and formats that computers can readily search, aggregate, and analyze, such as drop-down selections and coded diagnoses.

A controlled, agreed-upon set of terms and codes used consistently across systems so that clinical concepts can be shared, compared, and analyzed reliably.

Systematized Nomenclature of Medicine Clinical Terms, a comprehensive coded vocabulary of clinical concepts used to represent findings, procedures, and diagnoses in health records.

The International Classification of Diseases, Tenth Revision, Clinical Modification, a standardized coding system used to classify diagnoses for billing, reporting, and public health statistics.

The safeguards, including administrative, physical, and technical controls, that protect health information from unauthorized access, alteration, disclosure, or destruction.

A method of mapping the steps, roles, and handoffs in a clinical process to understand current practice and identify where technology or redesign can improve efficiency and safety.

Reduced clinician responsiveness to system warnings caused by too many or low-relevance alerts, which can lead to ignored important warnings and safety risks.

The sequence of tasks, decisions, and interactions that clinicians perform to deliver care, including documentation, communication, and coordination among team members.

Recording clinical data at the time and place care is delivered, often using mobile devices, to improve accuracy, timeliness, and completeness of the record.

A programmed logic statement that triggers a specific action or message when defined patient data conditions are met, such as a reminder when a screening is overdue.

A federal regulation establishing standards for protecting individually identifiable health information and governing when and how it may be used or disclosed.

A federal regulation requiring administrative, physical, and technical safeguards to protect the confidentiality, integrity, and availability of electronic protected health information.

Individually identifiable health information created, received, or maintained by a covered entity or business associate, in any form, that is protected under privacy regulations.

A HIPAA principle requiring that uses, disclosures, and requests for protected health information be limited to the least amount reasonably needed to accomplish the intended purpose.

A federal incentive program that required eligible hospitals and providers to demonstrate use of certified EHR technology in specified ways to improve quality, safety, and exchange of health information.

The knowledge, skills, and attitudes a nurse needs to use information and technology effectively, safely, and ethically in the delivery of care.

The application of knowledge, skills, and methods to plan, execute, monitor, and close a time-limited effort that delivers a defined product or system.