Use of Standardized Nursing Languages Discussion Paper

Standardized terminology is necessary for the exchange of consistent and reliable information between providers and settings (known as interoperability). After all, confusion occurs when health care professionals across disciplines are documenting patient problems, interventions, and outcomes in their own “set” language.
Within the current milieu of patient-centered care, the meaningful use initiative mandates that the SNOMED CT program be used for standardizing EHR terminology. SNOMED CT utilizes the Integrated Problem List (IPL) to facilitate an accurate health information exchange to ensure continuity of care.
To prepare for this Discussion:
Review the following from this week’s Resources:
Review the pages in the U.S. Department of Health and Human Services document SNOMED CT® and the Integrated Problem List (IPL) FAQ’s. Reflect in particular on Section 12.0, “Clinical Indication,” and Section 13.0, “Nursing Specific Questions.”
Consider how standards, standardized data, and interoperability benefit the quality, safety, and costs of care.
View the video The Path to Interoperability from the Office of the National Coordinator for Health Information Technology.  Use of Standardized Nursing Languages Discussion Paper
Think about how standardized data that can be accessed from any location and on any device may benefit patients and your nursing practice.
Contemplate how the change to an IPL will impact nursing care plans and the use of standardized nursing languages such as NANDA, NIC, and NOC.
By Day 3
Post the following:
Explain how standardized data accessed from any location and on any device may benefit patients and your nursing practice.
Describe how standardized data benefits the quality, safety, and costs of care. Explain why this is important for nursing practice.
Explain how the IPL will impact nursing care plans and the use of standardized nursing languages.

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Standards and Interoperability

Explain how standardized data accessed from any location and on any device may benefit patients and your nursing practice.

Standardized data benefits patients and nurses through supporting clinical decision-making and facilitating improved sharing of information as patients transition from one sector of the health care system to another sector. In fact, it improves and enhances communication among nurses and other health care providers. In addition, it increases visibility of nursing interventions. Besides that, it improves patient care by allowing for specific nursing interventions. Additionally, it enhances data collection to evaluate nursing care outcomes. Also, it facilitates assessment of nursing competency. Furthermore, it ensures greater adherence to standards of care (Rutherford, 2008).

Describe how standardized data benefits the quality, safety, and costs of care. Explain why this is important for nursing practice.

Standardized data benefits the quality, safety and cost of care. Firstly, it benefits quality by eliminating unnecessary work for nurses so that they have more time to spend with patients. Secondly, it benefits safety by ensuring that nursing care adheres to best practices so that opportunities for errors and mistakes are eliminated. It ensures that communication is concise and clear. Thirdly, it helps with cost saving through ensuring that care focuses on common practices that are reproducible and measurable, and have been proven to work. This is important for nursing care since it improves efficiency and effectiveness of care delivery while improving care outcomes (Kubben, Dumontier & Dekker, 2019).

Explain how the IPL will impact nursing care plans and the use of standardized nursing languages.

The integrated problem list (IPL) facilitates patient care continuity by offering an accessible and comprehensive list of the problems affecting the patient. It includes injuries, illnesses, and other factors that affect the individual patient’s health, as well as when the factor occurred, when it was identified and when it was resolved. This has an impact on care plan by capturing knowledge that directs the care plan. In addition, it helps with standardizing nursing languages so that the same communication vehicle is used throughout the while care continuum (Kubben, Dumontier & Dekker, 2019).

References

Kubben, P., Dumontier, M. & Dekker, A. (2019). Fundamentals of Clinical Data Science. Springer.

Rutherford, M. (2008). Standardized Nursing Language: What Does It Mean for Nursing Practice? OJIN: The Online Journal of Issues in Nursing, 13(1). https://doi.org/10.3912/OJIN.Vol13No01PPT05 . Use of Standardized Nursing Languages Discussion Paper