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Week 3: Knowledge and Information Management

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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Importance of documenting care using standardized nursing languages

Firstly, using a standardized language makes it possible for better communication among nurses as well as other health care providers (ANA, 2015). Through this system, there is increased visibility of nursing interventions. According to various researches, patient outcome also relies on using standardized language (ANA, 2015). Nursing language is a stable communication network that also promotes patient care and greater adherence to standards. Standardized nursing languages and documentation helps to build a consistent nursing research through data generation regarding patient care.

Secondly, nurses also use standardized language for nursing diagnosis as well as interventions. As such, this allows nurses’ activities to compliment medical diagnosis and their impact on patient outcomes. A good is example is when a patient has a chronic renal failure. In medical terms, the diagnosis of this condition is simply identified as ICD-9 code #585 (ANA, 2015). On the other hand, normal nursing diagnosis links renal failure with wide symptoms such as, fatigue, activity intolerance, excess fluid, risk for injury, and risk for infection, death anxiety excess fluid volume and such. In order for nurses to find accurate and simple diagnosis language and intervention, it is easy to click on the ideal information system that has the best evidence.

Should The Implementation Of Nursing Standardized Language Be Limited?

According to McGonigle & Mastrian (2015), using standardized language should be uniform across all nursing practice. The effectiveness of the practice should encourage all health care organizations to adopt the system for the sake of providing better health services. As stated earlier, the benefits of using nursing terminologies is evident in terms of patient outcome as well as increased visibility in nursing interventions. There are numerous efforts in place that capture the work of nurses using codes and computerized formats. This implies that the medical sector is making use of the opportunity to ensure that there is the establishment of computerization of nursing language (McGonigle & Mastrian, 2015). Despite the fact that the implementation of nursing code is costly, administrators and clinical nurses are working towards the adoption of standardized language across the board.

Personal Reflection

As a registered nurse, nursing language is a vital tool when I am communicating with other nurses and health care providers. The names and elements of nursing care become easy to comprehend and communicate between and among nurses. During health care provision, the use of standardized language helps to provide clarity about medical matters. As a result, leads to a better level of caregiving and patients’ safety (McGonigle & Mastrian, 2015). From a personal level, standardized nursing language is one of the ways that a health care giver can use to reduce complexities when giving a diagnosis. As a result, this helps to speed the process of care giving.

Conclusion

There are several benefits of using nursing terminologies. It is evident that the adoption of codes in nursing is now in practice. Despite the fact that the implementation is costly, it is necessary to keep the practice going for the sake of improving health care. Standardized language is a major step in reducing medical errors. However, there needs to be nursing language that comprises of researched-based terminology. It is also important to note that there are significant differences in nursing language. It is upon the nurses to pick the language that suitable for their situation. Otherwise, standardized language is an effective tool in promoting correct diagnosis and improving patient outcome.

References

American Nurses Association. (2015). Nursing informatics: Scope & standards of practice (2nd

ed.). Silver Springs, MD: Author.

McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge

(3rd ed.). Burlington, MA: Jones and Bartlett Learning.