Essay on The Impact Of Standardized Nursing Terminology
Standardized Nursing Terminology is terms that are commonly used and shared among users. Mostly in health care, the set of terms are needed to perfectly and evidently document the assessment s of clients’ outcome.
I would convey to nurses and others the importance of standardized nursing terminologies that it helps in learning ways of establishing, evaluating as well as using health information to deliver health care of high quality and also improve evidence-based practice. The use of nursing terminologies can also establish the line that divides a health care organization that is efficient from an inefficient one.
Enhancement of data collection for evaluating the outcome of nursing care, the nursing terminology helps in providing a consistency that is important in relating different nursing outcomes across settings. For instance, most organizations are adopting electronic documentation, and if the data is stored in nursing terminologies it will help in facilitating the benchmark with other health facilities as well as settings for providing nursing care. [ CITATION Mac17 \l 1033 ]says that the outcomes of patience have a relation of uniqueness for every individual depending on the care that is provided by a health care professional. Therefore, the collected data with similar units can be used for comparison with other organization and is sent back to a contributing organization and this assists longitudinal benchmarking in their database.
Another benefit is that it facilitates the assessment of nursing proficiency. Health care facilities are obligated to show the proficiency of the staff on behalf of the joint commission. For instance, the nursing language is useful in standardizing assess nursing proficiency when performing nursing interventions. To establish a nurse’s proficiency a preceptor will watch to see if a nurse is carrying out the activities that they are recommended like examining virginal or assessing the presentation of the fetus. Also, the preceptor can assess the teaching skills of a nurse concerning what is expected of a patient during labor, with the use of listed activities under teaching intervention(Strudwick, 2016).
Besides, there is better communication between nurses as well as health care professionals. [ CITATION Myk16 \l 1033 ] says that there is enhanced communication with health care providers, administrators as well as nurses of an institution where nurses’ work is the main advantage of using a Standardized Nursing language. For example, when a patient’s chart is listed as “failure to progress” by an obstetrician or the diagnosis is named as paranoid schizophrenia, chronic by a psychiatrist, other health care practitioners and physicians will understand the diagnosis of a patient.
Also, there is improved perceptibility of nursing interventions. Nurses are supposed to definite whatever they do to patients. For instance, since nurses report to one another verbally using informal notes, instead of the care plans and records of a patient, their work is not visible. (Pearson, 2003 Essay on The Impact Of Standardized Nursing Terminology ) points out that the use of systems that are computerized for nursing documentation that is closely located to a patient will result in frequent consistent documentation. Improved sensitivity to the activities of nursing care that the computerized systems assist shows the contribution outcomes of a nurse to patient and this makes nurses more visible.
Challenges of implementing standardized nursing terminologies in nursing practice include:
Health care professionals and nurses face several standardized nursing terminologies as they document diagnoses and assessments that are associated with procedures and labs which found in electronic health record from standardized coding systems like, LOINC, ICD-9, etc. at the time they are forced to associate procedures and also texts with conditions that patients don’t present. For example where a physician picks ICD-9 codes to associate with a scan of CT as there was no option for epiploic appendicitis and his best option was diverticulitis. The above conditions are not similar and this is a challenge that healthcare providers face since they have to pick from a category of standardized nursing terminologies in an electronic health record (Association, A. N. 2006).
Another challenge is that it is not possible to create a single list of standardized terminologies that satisfy the needs of everyone since the medical field is ever-changing and also complex. The physicians put a lot of effort as they try to get a solution for the right diagnosis from the standardized nursing terminologies list while it takes away important face time with their patients. Also, since different EHRs have different vocabularies, mapping has shown great hurdle interoperability. As the question of how to keep updating standardized list since new terminologies are formed while the old ones retire.
From the above, it is safe to say that standardized nursing terminologies are not only done because it’s useful but is done to assist in demonstrating and delivering nursing career and values. Its benefits include; improved perceptibility of nursing interventions facilitates the assessment of nursing proficiency, Enhancement of data collection for evaluating the outcome of nursing care, and there is better communication between nurses as well as health care professionals. It also faces challenges like several standardized nursing terminologies which is difficult to document, standardized terminologies are ever changing making it difficult to create a list of them. Despite the challenges standardized terminologies can help nurses improve the care their offer to their patients and can make nursing more visible.
Essay on The Impact Of Standardized Nursing Terminology References
Association, A. N. (2006). NCNQ, Home of the NDNQI. Retrieved January 15, 2006, from www.nursingworld.org/quality/ .
Macieira, T. G. (2017). Evidence of Progress in Making Nursing Practice Visible Using Standardized Nursing Data: a Systematic Review. In AMIA Annual Symposium Proceedings (Vol. 2, p. 1205). American Medical Informatics Association.
Mykkänen, M. M. (2016). Standardized Nursing Documentation Supports Evidence-Based Nursing Management. In Nursing Informatics (pp. 466-470).
Pearson, A. (2003). The role of documentation in making nursing work visible. International Journal of Nursing Practice, 9(5), 271.
Strudwick, G. &. (2016). Understanding the use of standardized nursing terminology and classification systems in published research: A case study using the International Classification for Nursing Practice®. International