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 dont 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.
Write 3-4 paragraphs and explain 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.
Notes: this assignment does not require tilt page or headers/footers
All the references are uploaded as a separate doc.
References
American Nurses Association. (2015). Nursing informatics: Scope & standards of practice (2nd ed.).Silver Springs MD: Author.
o Metastructures Concepts and Tools of Nursing Informatics
McGonigle D. & Mastrian K. G. (2012). Nursing informatics and the foundation of knowledge (2nd ed.). Burlington MA: Jones & Bartlett Learning.
Chapter 7 Developing Standardized Terminologies to Support Nursing Practice
Rutherford M. A. (2008). Standardized nursing language: What does it mean for nursing practice?OJIN: The Online Journal of Issues in Nursing 13(1). Retrieved fromhttp://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursingLanguage.html