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Week 3: Knowledge and Information Management #Solved

What words do you use to describe pain? What words do your colleagues use to describe pain? Does every patient use the same adjectives when discussing his or her level of pain? Consider the problems these differences can create when attempting to assess a patient’s health concerns.

Health information technology has greatly increased the opportunity for the exchange of meaningful data and information across health care systems; however, in order for that to successfully occur, care must be taken to ensure that patient data is entered in a manner that allows for that information to retain its meaning across different systems. To be able to use health information technology to its greatest advantage, nurses need to gain an understanding of how data and information can be standardized and organized.

This week, you assess the purpose of standardized terminology in informatics. In addition, you are introduced to the continuum of data, information, knowledge, and wisdom, and you consider the key elements of each stage.

Discussion: Standardized Coding Systems

As a result of the fragmented nature of the health care system, professionals in various specialty areas of medicine have developed their own unique sets of terminology to communicate within that specialty. In the past, limited attention has been given to codifying practices in order for them to be understood and utilized across disciplines or through different information technology systems. The implementation of a federally mandated electronic medical records system, therefore, poses a challenge to nursing professionals and others who must be prepared to utilize standardized codes for the new system. Why are coding standards important for promoting consistent, high-quality care?

According to Rutherford (2008, para. 15), “Improved communication with other nurses, health care professionals, and administrators of the institution in which nurses work is a key benefit of using a standardized nursing language.” In this Discussion you consider the reasoning behind and the value of standardized codification.

To prepare

  • Review the information in Nursing Informatics: Scope and Standards of Practice. Determine which set of terminologies are appropriate for your specialty or area of expertise.

  • Reflect on the importance of continuity in terminology and coding systems.

  • In the article, “Standardized Nursing Language: What Does It Mean for Nursing Practice?” the author recounts a visit to a local hospital to view its implementation of a new coding system. One of the nurses commented to her, “We document our care using standardized nursing languages but we don’t fully understand why we do” (Rutherford, 2008, para. 1). Consider how you would inform this nurse (and others like her) of the importance of standardized nursing terminologies.

  • Reflect on the value of using a standard language in nursing practice. Consider if standardization can be limited to a specialty area or if one standard language is needed across all nursing practice. Then, identify examples of standardization in your own specialty or area of expertise. Conduct additional research using the Walden Library that supports your thoughts on standardization of nursing terminology.

Questions to be answered

1.Post an explanation of why nurses need to document care using standardized nursing languages and whether this standardization can be limited to specialty areas or if it should be across all nursing practice.

 2.Support your response using specific examples from your own specialty or area of expertise and using at least one additional resource from the Walden Library.

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