Among the Resources in this module is the Rutherford (2008) article Standardized Nursing Language: What Does It Mean for Nursing Practice? In this article, the author recounts a visit to a local hospital to view the recent implementation of a new coding system.
During the visit, 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).
How would you respond to a comment such as this one?
To Prepare:
Review the concepts of informatics as presented in the Resources, particularly Rutherford, M. (2008) Standardized Nursing Language: What Does It Mean for Nursing Practice?
Reflect on the role of a nurse leader as a knowledge worker.
Consider how knowledge may be informed by data that is collected/accessed.
Instructions:
In a 2- to 3-page paper, address the following:
Explain how you would inform this nurse (and others) of the importance of standardized nursing terminologies.
Describe the benefits and challenges of implementing standardized nursing terminologies in nursing practice. Be specific and provide examples.
Be sure to support your paper with peer-reviewed research on standardized nursing terminologies that you consulted from the Walden Library.
The Impact of Standardized Nursing Terminology
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The Impact of Standardized Nursing Terminology
Standardized nursing languages are important in the use of electronic documentation and the utilization of electronic health records technology. The standardized nursing language and vocabulary is important in the description of the key components of the care process. Understanding the nursing languages provide benefits to the outcomes of the patients and nursing practice. The standard nursing language should be communicated to make sure that nursing care has been understood among nurses and health care providers. Standardized language in nursing involves the clinical area, which is beneficial at different capacities to the nurses.
Standardized nursing language enhances better communication among the nurses and other health care providers in the organization. It is also through the utilization of the standard nursing terminology that nurses experience increased visibility of the nursing interventions and improved patient care. It will involve the provision of the computerized documentation systems to nurses that help in the highlighting of the contribution of the nurses to the patient outcomes to make the interventions of nursing more visible. Besides, the standardized nursing terminologies include the observation skills and experience in making required nursing judgments concerning the health of the patients and the care of the patient.
Effective utilization of standardized nursing language works towards improving patient care. Standardized nursing terminologies allow the nurses to identify the chief complaints mostly, the areas of pain management activities and the change of NOC outcomes after the intervention. Standardized nursing language is vital in the provision of the consistency required in the recording of nursing care and comparison of the quality of outcome from various nursing interventions.
When standardized nursing language is used in the storage of the nursing care data, it influences and improves the construction of the large state, local and national data repositories for the facilitation of benchmarking involving other hospitals and settings in the provision of nursing care. As a Health care facility, the standardized nursing language is useful in the assessment of nursing competency in the performance of interventions. The nursing competency can be established through watching by a preceptor to see whether the nurse is performing recommended activities and the Assessment of the nurse’s teaching skills through evaluating what the patient expects during labor and the use of activities under the teaching intervention.
The implementation of the standardized nursing terminologies in nursing practice include the association of tests and procedures with diagnoses and conditions. It happens when a patient is found with lower abdominal pain, and on further examination and diagnostic, a rare condition of epiploic appendagitis is found on the patient. However, the physician in the recording finds there is no option for epiploic appendagitis; therefore, the used diverticulitis. These two conditions are not the same, and that is an obstacle in picking involve in the standardized terminologies.
The ways are difficult and the complexities in the description of a condition made available by standardized coded diagnoses and assessments. These ways lead to the difficulty that the standardization does not capture the true essence of the condition of the patient and patient care provided and thereby results in documentation of findings and diagnoses in unstructured data forms in the electronic health records with dictation and narratives. As a result, the data is difficult to map and also difficult to extract for research and billing purposes.
References
Adubi, I. O., Olaogun, A. A., & Adejumo, P. O. (2018). Effect of standardized nursing language continuing education programme on nurses’ documentation of care at University College Hospital, Ibadan. Nursing open, 5(1), 37-44.
De Groot, K., De Veer, A. J., Paans, W., & Francke, A. L. (2020). Use of electronic health records and standardized terminologies: A nationwide survey of nursing staff experiences. International Journal of Nursing Studies, 104, 103523.
Mollie Cummins, R. N. (2016). Standardized nursing data and the oncology nurse. Clinical Journal of Oncology Nursing, 20(3), 336.
