Standardized Coding System Example Paper

Discussion: 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.

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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.
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.  Standardized Coding System Example Paper

Standardized coding system

Over the course of every year, nursing personnel in the USA handle more than 5 billion cases requiring their professional services. To ensure that their services are understood by their peers in a consistent and orderly manner, they make use of standardized coding systems. In this case, the systems act as a set of terms that describe their set of clinical strategies applied in making diagnoses and case assessments, along with treatment and outcomes as they relate to care documentation (Cherry & Jacob, 2016). The system contains three forms of data. The first form is reference terminologies that present common semantics for a wide range of uses and allowing nursing personnel to communicate discipline-specific practices to other medical professionals. The second form is interface terminologies that comprise nurse-specific concepts and terms to document and describe nursing care. The final form is minimum data sets that use codes to define specific purposes in contextual terms to influence care. For that matter, the system is uniform tool that comprises of identifying codes and descriptive terms that principally identify nursing procedures and services furnished by nurses (Finkelman & Kenner, 2016). In this respect, standardized coding systems are tools that nursing personnel apply to represent the professional procedures and services they offer.

The development of standardized coding system has been galvanized by the need for interoperability and adoption of medical technologies to improve health care outcomes. In fact, the new environment has created a need for consistent and common elements and standards that act as the foundation for advancing care models. This is further supported by the need to capture sharable data elements across different settings, with the codes enabling less arduous and more precise measurements of care quality as delivered while supporting ongoing analysis and research efforts. Within this context, nurses can present large amounts of important data that are linked to nursing processes and patients’ care (Marquis & Huston, 2017). To understand the position of the standardized coding system, it is important to note that although the data presented by nursing personnel is important, its value and contribution to care outcomes would be diminished if it is not presented in a standardized format or becomes difficult to translate. This is a comprehensible concern since the national nursing workforce has approximately 4 million members who spend more than half of their professional time in offering direct care. With nursing personnel forming the largest single medical profession and with the need to improve care outcomes through forward thinking and innovative strategies, it is understandable that omitting data from nurses would be unfortunate (Black, 2016).

Rather than use in specialty areas, standardized coding system should be used across all nursing practices. That is because the system is intended to improve communication, an admirable objective irrespective of specialty. In fact, using the system across all nursing practices would offer six main benefits. The first benefit is that using the system results in improved visibility of nursing interventions. The second benefit is that it eases the process of assessing the competency of nursing personnel. The third benefit is that it improves communication between nursing personnel and with other health care stakeholders. The fourth benefit is that it ensures greater adherence to established standards of care. The fifth benefit is that it improves health care interventions and outcomes. The final benefit is that it enhances the data collection to evaluate nursing care outcomes. These benefits can only be realized by applying the system across all nursing practices (Porter-O-Grady & Malloch, 2016).

References

Black, B. (2016). Professional nursing-e-book: concepts & challenges. Amsterdam: Elsevier Health Sciences.

Cherry, B. & Jacob, S. (2016). Contemporary nursing: issues, trends, & management. Amsterdam: Elsevier Health Sciences.

Finkelman, A. & Kenner, C. (2016). Professional nursing concepts (3^rd ed.). Burlington, MA: Jones & Bartlett Learning.

Marquis, B. & Huston, C. (2017). Leadership roles and management functions in nursing: theory and application (9^th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

Porter-O’Grady, T. & Malloch, K. (2016). Leadership in nursing practice: changing the landscape of healthcare (2^nd ed.). Burlington, MA: Jones & Bartlett Learning.  Standardized Coding System Example Paper