PresentationHealth information systems

Healthcare Data Standardization DQ

A system with no data dictionary is a system where the same clinical fact is recorded four ways. That is the issue to lead with, and it is what standard languages exist to fix.

Editorial process

Last reviewed · August 25, 2026

Written by

Maren Caldwell

MSN, RN, CNE

Medical-surgical nursing, pharmacology and NCLEX preparation

Reviewed by

Dr. Tessa Redmond

DNP, RN, CNE

Evidence-based practice and clinical education

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Interpret the task
Assignment instructions
Deliverables
Proposed outline
Research plan
Reference shortlist
Final review

No data dictionary means no comparable data

The case is unusually specific and every detail is a hook. Two issues are already handed to you and they are the strongest ones available. Free text at fifteen to twenty percent means a fifth of clinical documentation cannot be found by a query, so quality reporting, research and any clinical decision support are all working from a partial record without saying so. The absence of a data dictionary is the deeper problem, because terms chosen in-house by a development team mean the same clinical concept can be captured differently on different screens with no authoritative definition to reconcile them, and the newly acquired clinics and practices now being converted make that worse by adding populations whose documentation conventions were formed somewhere else. Both issues are already in the case, which means you can evidence them from the scenario itself rather than from general claims about legacy systems.

For the terminology section, answer the three attributes the brief names rather than describing each language in general. A nursing-only standard language covers nursing diagnoses, interventions and outcomes, and the point to make to clinical staff is that it makes nursing work visible in data that would otherwise show only medical and billing activity. A multidisciplinary language covers clinical concepts across professions and is the reference terminology that others map into. Cross-maps are what let a nursing terminology's content be expressed in the reference terminology, which is how a nursing concept survives a query written by someone else, and update frequency matters because a terminology that releases twice a year and one that releases annually will drift apart between synchronisations. Then write the survey questions as genuinely open-ended, since the brief says so explicitly and a question answerable with yes tells you nothing about how the transition should be supported.

Likely learning objectives

Explain free-text documentation as a data retrievability problem.
Explain why the absence of a data dictionary prevents comparable data.
Distinguish a nursing-only terminology from a multidisciplinary reference terminology.
Write open-ended survey questions that surface transition needs.

Assignment instructions

Read the full question

Review every instruction before using the planning guidance that follows.

A small community hospital in the Midwest has used a homegrown information system for years. The system began in the early 1970s with a financial module. Over time, additional modules were added. A limited number of departments selected a commercial system and interfaces were used to integrate these into the overall functionality of the hospital information system. Except for physicians, most in-house clinical or care-related documentation is online. However, about 15% to 20% of this documentation is done by free text and is not effectively searchable. In addition, the screens, including the drop-down and default values, were built using terms selected by the in-house development team in consultation with clinical staff; thus there is no data dictionary or specific standard language. In the last few years, the hospital has purchased two outpatient clinics (obstetrics and mental health) and a number of local doctor practices. The clinics and doctors’ offices are now being converted to the hospital administrative systems. A few of the clinical applications that are tied directly to the administrative systems such as order entry and results reporting are also being installed. A major change is being planned. A new chief information officer (CIO) was hired last year and she has appointed a chief medical information officer (CMIO) and a chief nursing information officer (CNIO). No other significant staff changes were made. With her team in place, one of the CIO’s first activities was to complete an inventory of all applications. Rather than continue to build, a decision was made to switch to a commercial vendor and the hospital selected a commercial system. As a member of the clinical staff with informatics education, the CIO has requested that you develop a training and information presentation for the clinical staff that will: 1· Identify two or more issues with the existing system 2· Provide staff with appropriate “work-around” for using the existing system 3· Provide an overview of two of the standard languages used within the new system including discipline or specialty, updating frequency, and available cross-maps – One standard language should pertain only to nursing – One standard language should be multidisciplinary. 4· Obtain clinical staff input, using a five-question survey, of specific methods to support transition to the new system; questions should be open-ended. PowerPoint Presentation Directions: 1. Review the case study. 2. Download the provided PowerPoint template to create a presentation that includes: · Your name on the title slide of the presentation · Identification of two or more issues with existing system · Identification of “work-a-round” solutions when using existing system · Overview of standard language used only in nursing · Overview of multidisciplinary standard language · Set of five (5) open-ended survey questions for staff input on transitioning to the new system Presentation is free of spelling and grammar errors.

What the presentation must contain

01A PowerPoint presentation using the provided template, with your name on the title slide.
02Identification of two or more issues with the existing system.
03Appropriate workarounds for using the existing system.
04An overview of two standard languages used in the new system, including discipline or specialty, updating frequency and available cross-maps.
05One standard language pertaining only to nursing and one that is multidisciplinary.
06A set of five open-ended survey questions for clinical staff input on the transition.
07A presentation free of spelling and grammar errors.