Introduction: Standardized terminology is key to the introduction of a uniform electronic documentation in healthcare. It provides accurate communication by eliminating and reducing the ambiguity of the language, which in turn improves the documentation. An integrated model of standard terminology can help to better communicate and coordinate the planning of healthcare treatment by all health professionals. Purpose: This diploma thesis will explore the knowledge of standardized terminology among nurses and the impact of standardized terminology on electronic documentation. We will also explore the impact of informatics on documentation requirements in the nursing care. Methods: We used a descriptive research method, and also, a systematic review of literature was made. The period of publication of the searched literature was from 2006 to 2017. We searched for literature in Slovene and English in CINAHL databases (Cumulative Index of Nursing and Allied Health Literature), Medline (Medical Literature Analysis and Retrieval System Online), Google Scholar and COBIB. SI. We identified 327 units and 26 articles were included in the analysis. Results: There is little research in the field of standardized terminology in Slovenia. In the rest of the world, health care documentation was developed using information and communication technology in unified electronic systems. They were supported by experts in the field of informatics. Foreign researchers believe that standardized terminology should be used in electronic documentation, because it increases patient safety, reduces errors and prevents various interpretations. Discussion and conclusion: The use of standardized terminology has raised the quality of documentation in nursing care. For nursing care it would be useful to include standardized terminology in combination with electronic documentation. Researchers confirm that healthcare professionals are refusing to work with their computers, while not having sufficient knowledge of information technology and the use of information and communication technology. By introducing standard terminology in nursing, the quality of communication in the health sector would greatly increase, leading to better patient nursing care.
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