Knowledge and Information Management

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.

Knowledge and Information Management

Information has always been an important element of in healthcare practice. Since the
1970s, most health care organizations have endeavoured to develop systems that manage
resources more efficiently. Health care information must be accessible and available to more the
practitioners, it must have a life span that expands beyond the clinical encounter and must also

serve various purposes. Although traditional currencies such as handwriting, speech, or text have
been flexible and powerful representations, they have failed to withstand the current and future
demands subjected on information, and this has led to the development of standardized
terminologies such as nomenclatures, classifications, controlled vocabularies as well as
The use of standardized terminologies in nursing has several benefits. For instance,
McGonigle & Mastrian, (2015) point out that standardization aids in improving communication
not only among nurses but also with other health care providers as well as their administrators.
The use of classifications such as the Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV) is one of the approaches that has been used to offer a common language during
characterization of mental disorders depending on their manifestations. Through the DSM-IV,
psychologists can describe a patient to be paranoid schizophrenic or Attention Deficient
Disorder. With these other clinicians or third party, players can comprehend the diagnosis and
provide the patient with appropriate care.
According to Rutherford, (2008), practitioners need to elaborate exactly what they
patients’ care plans. All professionals are required to communicate to other what exactly they
have done to patients. The use of word of mouth or simple, informal notes as a form of
documentation instead of patient records or care plans makes the entire process invisible
(American Nurses Association, 2015). It is for this reason that nurses should use standardized
languages such as computerized documentation systems to which not only make the entered
information easy to retrieve but also promotes patient-centered care as well as consistent
documentation. Also, the increased sensitivity associated with the use of standardized languages

aids in highlighting the contribution of nurses in improving the quality of life of patients hence
making the nursing process more visible.
Use of standardized languages in nursing practice should also be encouraged majorly
because it helps in improving patient care(Bickford, 2015). With standardized terminologies,
nurses can conduct studies on patients tabulate the results in a common language and determine
whether there are any consistencies in the findings. This can be done for example when different
practitioners want to identify causes of lack adherence among patients with chronic conditions in
various health care institutions. All these researchers will report their results in common
language and therefore can meet discuss their findings and come up with appropriate
interventions that are patient-specific. Without standardization, the report could be done
differently hence creating confusion and hindering the process of care of patients.
Standardized communication plays a major role in assessing nursing competency. Health
care facilities should have the competence of staff for the Joint Commission. For example, the
use of the NIC system can be utilized by a preceptor to establish a nurse’ expertise to find out if
the nurse is undertaking all recommended activities. The teaching skills of a nurse can also be
assessed so that they are in line with what the patient should do after he/she has been discharged.
Standardization should be applied across all nursing practice because they promote
communication not only within a given institution but also nationally and internationally. This
facilitates multidisciplinary practice whereby every practitioner can understand whatever the
others are talking about and contribute towards improving patient outcomes. For instance, when
reporting of the diagnosis of a patient who has been through sexual violence, the diagnoses can
either be a rape-trauma syndrome, a risk of infection, acute pain, anxiety or acute pain. Through

the use of these terminologies, nurses can comprehend what their colleagues are communicating
and provide patient-centered care.



American Nurses Association. (2015). Nursing Informatics: Scope & Standards of practice (2nd
ed.). Silver Springs, MD: Author.
Bickford, C. J. (2015). The speciality of nursing informatics: New scope and standards guide
practice. CIN: Computers, Informatics, Nursing, 33(4), 129-131.
McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge
(3rd ed.). Burlington, MA: Jones and Bartlett Learning.
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice.
OJIN: The Online Journal of Issues in Nursing, 13(1), 243-50.