The importance of continuity in terminology and coding systems
Readings
American Nurses Association. (2015). Nursing informatics: Scope & standards of practice (2nd ed.). Silver Springs, MD: Author.
“Metastructures, Concepts, and Tools of Nursing Informatics”
This chpater explores the connections between data, information, knowledge, and wisdom and how they work together in nursing informatics. It also covers the influence that concepts and tools have on the field of nursing.
McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (2nd ed.). Burlington, MA: Jones & Bartlett Learning.
Chapter 6, “Overview of Nursing Informatics”
This chapter defines the foundations of nursing informatics (NI). The authors specify the disciplines that are integrated to form nursing informatics, along with major NI concepts.
Chapter 7, “Developing Standardized Terminologies to Support Nursing Practice”
This chapter explores the need for consistent nursing terminology. The authors also detail the different approaches to developing terminology.
Brokel, J. (2010). Moving forward with NANDA-I nursing diagnoses with Health Information Technology for Economic and Clinical Health (HITECH) Act Legislation: News updates. International Journal of Nursing Terminologies & Classifications, 21(4), 182–185.
Retrieved from the Walden Library databases.
In this news brief, the author describes the initiatives that NANDA-I will implement to remain abreast of the HITECH legislation of 2009. The author explains two recommendations for the federal government’s role in managing vocabularies, value sets, and code sets throughout the health care system.
Matney, S., Brewster, P. J., Sward, K. A., Cloyes, K. G., & Staggers, N. (2011). Philosophical approaches to the nursing informatics data-information-knowledge-wisdom framework. Advances in Nursing Science, 34(1), 6–18.
Retrieved from the Walden Library databases.
This article proposes a philosophical foundation for nursing informatics in which data, information, and knowledge can be synthesized by computer systems to support wisdom development. The authors describe how wisdom can add value to nursing informatics and to the nursing profession as a whole.
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 from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursingLanguage.html
The author of this article provides justification for the use of a standardized nursing language, which will be necessary for incorporating electronic documentation into the health care field. The author defines standardized language in nursing, describes how such a language can be applied in a practice setting, and discusses the benefits of using a standardized language.
Westra, B. L., Subramanian, A., Hart, C. M., Matney, S. A., Wilson, P. S., Huff, S. M., … Delaney, C. W. (2010). Achieving “meaningful use” of electronic health records through the integration of the Nursing Management Minimum Data Set. The Journal of Nursing Administration, 40(7–8), 336–343.
Retrieved from the Walden Library databases.
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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.
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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. 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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