NR 361 Discussion Standardized Terminology and Language in Informatics
NR 361 Discussion Standardized Terminology and Language in Informatics
NR 361 Discussion Standardized Terminology and Language in Informatics
North American Nursing Diagnosis International (NANDA) is one of the first terminologies used in nursing practice. In order to treat patients a nursing diagnosis has to be made first. “A nursing diagnosis is a clinical judgment about individual, family, or community experiences and responses to actual or potential health problems and life processes” (Hebda, Hunter, & Czar, 2019 p.304). A nursing diagnosis identifies patient reactions to health promotion, risk, and disease. In my understanding NANDA has 13 domains with two or more classes that will help identify a patient’s diagnosis. The nursing diagnoses are designed to focus the nurse’s care in relation to the patient’s needs. A nursing diagnosis includes a description, a definition, and defining characteristics. Manifestations, signs, and symptoms are defining characteristics that are used to help nurses to determine and assign the correct diagnosis for their patients. Nursing Interventions Classification (NIC), Nursing Outcomes Classification (NOC), and NANDA are associated together to standardized terminologies. The standard terminology for nurses was implemented into the nursing practice of planning and documentation so that nurses everywhere are using the same language to describe the care they are providing their patients. NANDA, NIC, and NOC help to document nursing problems, interventions, and outcomes which will improve in the care provided by all nurses.
In the detox nursing practice I work with several nurses. I think the standardized terminology helps nurses work together more efficiently. It also makes it easier to understand for everyone and it avoids miscommunication and errors. All nurses think differently so the standardization makes it clear across the board. “Standardized nursing language will facilitate communication among nurses and between nurses and other healthcare providers, provide inclusion of nurses work in clinical information systems, provide easy access to evidence-based knowledge stored in national and international databases, increase visibility of nursing interventions and improve patient care among others”(Gusen, Goshit, Dauda, Williams, & Danye, 2017, p.22).
References
GUSEN, N. J., GOSHIT, J. D., DAUDA, R., WILLIAMS, A. J., & DANYE, R. (2017). Nurses’ Knowledge Attitude and Practice of Standardized Nursing Language in Pssh, Jos. West African Journal of Nursing, 28(1), 21–31. https://chamberlainuniversity.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=125017004&site=eds-live&scope=siteLinks to an external site.
Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.
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Great post! Well written. In your nursing practice does your computer systems use NANDA, NIC or NOC? I have relied on using my NANDA upon my physical assessments and I keep on my clipboard of notes. MY office computer coding system does not offer the nursing diagnosis and I tend to add in my nursing notes when needed. I agree with you in that standardized terminology is very important to understand and helps with the communication with fellow healthcare team members. The nursing outcomes classification (NOC) is part of healthcare system to evaluate the effects of nursing care and consists of outcomes for our patients and family members that really help (Hebda, Hunter, & Czar, 2019). These elements are great for the nursing process and to help develop for the patients health care plan. To help improve quality nursing care nursing documentation has room for improvements. “Standardized terminologies (e.g. NANDA International and the Omaha System) are expected to enhance the accuracy of nursing documentation. However, it remains unclear whether nursing staff actually feel supported in providing nursing care by use of EHRs that include standardized terminologies” (De Groot, De veer, Paans, Francke, 2020). So understanding nursing documentation standardized terminology can help improve the quality care to our patients and families. Thank you!
References:
Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of Informatics for Nurses and Healthcare Professionals (6th ed.). Pearson. De Groot, K., De Veer, A., Paans, W., Francke, A., (2020). Use of electronic health records and standardized terminologies: A nationwide survey of nursing staff experiences. International Journal of Nursing Studies: Retrieved from Chamberlain School of Nursing Library.
This was an excellent description of NANDA! I looked up their organization and saw that the name was changed in 2002 to become NANDA International and then to NANDA International, Inc in 2011 (About Us, n.d.). The organization helps the healthcare industry worldwide, which is incredible. I love their guide book because it helps give the best interventions and desired outcome to best help our patients.
The standardized, or controlled terminology, does keep everyone on the same page and prevent errors in the healthcare field. Hebda et al (2019) agree that it “enables safe, patient-centric, high-quality healthcare that optimizes data collection for the measurement of patient outcomes” (p. 294).
Danielle P. Smith
References
About Us. (n.d.). Retrieved from from https://www.nanda.org/about-us/Links to an external site.
Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.
I would like to talk about usability in my practice. Usability simply explained by the ability to be used. “Good usability is critical for the adoption and safe use of health-information products…Concepts about usability guide informaticists in creating and purchasing technologies that users find effective, efficient, and satisfying to use.” (Hebda, 2019, P. 168.) Poor usability can result in decrease in productivity, errors, delayed treatment and decision, user frustration, underutilization of systems, deinstallations, and need for extra support. (Hebda, 2019)
In my opinion, electronic clinical documentation can improve the usability to reach the goal of effectiveness, efficiency, and satisfaction. “Evidently, the implementation of electronic clinical documentation is essential to enhance the provision of safe, ethical, and effective nursing care. Previous research presented that electronic documentation improved the completeness, quality of nursing documentation and quality of care. Another benefit of electronic documentation are nurses no longer have to waste time consulting with one another, trying to decipher someone’s dreadful handwriting, and fewer errors related to misinterpreted orders should follow.” (Harivati&Tutik, 2020) Point Click Care (PCC) was introduced to my rehab center two years ago. PCC absolutely plays a critical role to improve efficiency of nursing care. For example of the assessment of bowel movement and dehydration. With paper charting, I need to review every page for each patient to see when they have bowel movement and in&out to figure out if they need treatment. It normally took me about 30 minutes for 20 patients. With PCC, I just need to search key words “bowel movement” and sort result by patient’s name or room number or anything that is convenience for me. In this way, I just need up to 5 minutes to find the result.
References
Hariyati, Rr Tutik Sri, et al. “Usability and Satisfaction of Using Electronic Nursing Documentation, Lesson-Learned from New System Implementation at a Hospital in Indonesia.” International Journal of Healthcare Management, vol. 13, no. 1, Apr. 2020, pp. 45–52.
Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.
One standardized terminology that is very crucial in healthcare is the term Interoperability. Hebda, Hunter, and Czar define interoperability as “the ability to exchange information across systems” (Hebda, Hunter, & Czar, 2019, p. 156). I believe this especially important when caring for patients in a hospital setting, because so many members of the healthcare team need to document on the care provided. Many disease processes require multidisciplinary teams to treat and care for those patients. One example of this is the care for a stroke (CVA) patient. Once on an inpatient unit, members of the care team include attending physician, Neurology physician, nurses, pharmacist, physical therapist, occupational therapist, speech language pathologist, case manager, and possibly operating room nurses and Neurosurgeons or interventional radiology physicians and nurses (Clarke & Foster, 2015). At my hospital for example, all of these disciplines do not use the same program for charting. My hospital uses Cerner as their EMR system, but each discipline uses their own version. PT, OT, and SLP all use different forms for their charting, which are all accessible for nursing staff to view, but it is not as streamline as one would hope. The forms that PT, OT, and SLP use all include ICD coding, that us nurses are not taught to identify. OR and IR nurses use different charting programs that do not easily cross-over to inpatient nursing documentation. For this reason, many nursing interventions done in the OR or IR are not properly documented, such as new IV placements and indwelling catheter insertions. I believe interoperability in healthcare informatics definitely has room for improvement. The shift to all electronic medical records has greatly enhanced the outcomes for patients. Making all this documentation easy to read and more streamline would help inpatient nurses like me to connect the dots when doing research on my patients. Understanding what each discipline is doing will help the healthcare team members work better together.
References
Clarke, D. J., & Foster, A. (2015). Improving post-stroke recovery: the role of the multidisciplinary health care team. Journal of multidisciplinary healthcare, 8, 433-442. https://doi.org/10.2147/JMDH.S68764
Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.
“The broad goals of usability are promoting acceptance and use of systems through improved effectiveness (including safety), efficiency, and satisfaction. These goals are achieved by optimizing the use of interactive systems and software, developing new kinds of applications to support specific work, and promoting job optimization with the use of HIT”. (Hebda, Hunter, & Czar, 2019) One of the most used tools we use is of course the computer, where we do our charting, scan medications, check for new orders, and other miscellaneous things that need to be done. Through these tools and the more we learn from them allows us to be more effective, efficient and increase patient satisfaction. We recently had an update to our EMR, where all the things we need for covid are in one section, and all others in one section. Making it easier to deal with the workload if you’re working the covid unit. Swabs, medication, and request orders from MDs are in one block so we don’t continually have to radio or get a tech to run our orders. Collected blood samples or any other sample is easily collected and input into the appropriate section for collection as well to minimize the spread of any germs. When the pandemic initially started, and more and more patients were coming in to be seen, all of these tasks fell on nurses who worked the covid tents and it took forever to get through one patient. Everything was late, no one was collecting samples. Now that new implementations have been put in place, it’s a whole lot easier to get things done.
Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.
Harayati, R., Tutik, S., & Zainal, A. (2020, April). Usability and satisfaction of using electronic nursing documentation, lesson-learned from new system implementation. Retrieved July 21, 2020, from https://chamberlainuniversity.idm.oclc.org/login?url=https%3A%2F%2Fsearch.ebscohost.com%2Flogin.aspx%3Fdirect
I work with adults, so Medicare is a common thing the unit has to deal with. While I don’t really interact with Medicare directly, I know what I do and what I document can affect what is reimbursed to the hospital. Preventable things like falls or hospital-acquired pressure injuries and infections should never happen and negatively affect what Medicare pays. When a patient is admitted, it is our policy that two nurses look over the patient’s skin to find any pressure injuries or any other skin issues. If any pressure injuries are missed, it will impact our payment. Even if we know they had it when they came in, if it wasn’t documented within 24 hours of them arriving it is technically our fault. This strict documentation is important in all areas of healthcare, including skilled nursing facilities and long-term care facilities. One could argue that a SNF might be look at more closely considering the amount of time the patient will spend there.
The nurse at the SNF is required to do an initial assessment to see if the patient will qualify for their services and if Medicare will pay for those services. The nurse also documents diagnoses, conditions, functional limits, treatments, and any medications given. Everything that is documented is them subject to review by the billing department. Any documentation deficits will negatively affect the payment, therefore costing the SNF to lose money on services already provided (Micheletti, Shlala, & Greenfield).
Medicare will pay for what they believe is necessary and often times the rest falls onto the facility or hospital to pay. That’s why documenting everything that is required to make Medicare happy is so important.
Micheletti, J. A., Shlala, T. J., & Greenfield, C. E. (n.d.). Optimizing Medicare reimbursement in skilled nursing facilities. Healthcare Financial Management, 38-42.