Adoption of Standardized Terminologies in Practice

Discuss

A standardized nursing terminology is going to be implemented in your practice setting (administration, education, research, practice). Based on your chosen specialty, which standardized terminology would most likely be adopted and why?which standardized terminology would most likely be adopted and why?

Describe and discuss, the most important part of this post is the ‘why’).

Adoption of Standardized Terminologies in Practice

The care health practitioners offer to enable recovery, lighten suffering, maintain life, and improve health should be well documented in the electronic health record. There should be proper recording and storage of data in a standardized form to enhance sharing of information between care settings and clinical disciplines (Hardiker and Nagle, 2015). The best way of ensuring that patient data is stored in a manner that is not ambiguous is through the use of standardized terminologies. The field of nursing has several terminologies each developed for application in certain care settings (Matney and Lundberg, 2013). Institutions should therefore select and adopt an appropriate terminology that meets their needs.

My field of choice is nursing research. The best nursing terminology that can be used in this field is the Nursing Interventions Classifications (NIC). This is a detailed set of research-based interventions that are performed by nurses (Noh and Lee, 2015). NIC use promotes the study of the effect of nursing activities on the outcomes of the patient. Computerized documentation based on NIC can help researchers to use “real-time” data. This data is easily accessed and retrieved compared to the traditional method that is time consuming as it entails scrolling through stacks of tables to obtain the desired information.

When bedside nurses record information through NIC, the data is stored in a warehouse in the hospital. Trends in patient care are uncovered easily when researchers or administrators access this aggregated data. As a result, best practices of patient care are unlocked, nursing care efficiency is discovered, and relevant nursing knowledge is built. Stronger implications are also revealed when nursing research is conducted using large sample sizes enabled by NIC. Adopting NIC to document patient care can reflect precisely the care given, monitor levels of acuity as well as forecast appropriate staffing. Use of NIC in documentation can also offer important data to support reimbursement to a health care agency with regards to the care offer by practicing nurses.

References

Hardiker, N. & Nagle, L. (2015). Information and knowledge needs of nurses in the 21st century. In D. McGonigle & K. Mastrian (Eds.), Nursing informatics and the foundation of knowledge (3rd ed.). Sudbury, MA: Jones and Bartlett.

Matney, S. & Lundberg, C. (2013). The role of standardized terminology and language in informatics. In T. Hebda & P. Czar (Eds.), Handbook of informatics for nurses and healthcare professionals (5th ed.) (pp. 295–323). Upper Saddle River, NJ: Prentice-Hall, Inc.

Noh, H. K., & Lee, E. (2015). Relationships Among NANDA‐I Diagnoses, Nursing Outcomes Classification, and Nursing Interventions Classification by Nursing Students for Patients in Medical‐Surgical Units in Korea.International journal of nursing knowledge26(1), 43-51.

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