Uses of Standardized Nursing Terminology

Hello Professor Bowen and class, I never really gave it more thought than the fact that without standardized terminology, we couldn't communicate effectively throughout the different disciplines involved in healthcare. Standardized terminology is essential for safe, accurate documentation and communication among healthcare workers sharing information. Without this "EHRs can no longer be implemented."(Czar & Hebda, 2013 p.298) "Implementation of standardized terminology within the EHR is essential for healthcare organizations to meet the criteria of Meaningful Use."(Czar & Hebda, 2013 p. 298)This has made me realize how vital it is for us to maintain standardized terminology, it actually can effect financial reimbursement. It is important for others reading our nursing documentation to be understood the same within the different disciplines sharing the information. Our nursing documentation using nanda is an essential part of documenting the patients response and progression or lack there of, during hospital stay ." The NANDA-1 coding system can be used within the EHR either by mapping the nursing problems that nurses document directly or by mapping to NANDA-1, NIC and NOC linkages." (Czar & Hebda, 2013 p.309) As we all know well, if we didn't document it, it didn' t happen. Nurses documentation needs to be indicative of the care we gave the patient, not geared to litigation alone. Also our detailed documentation in the HER facilitates nursing competencies. We had a company come review our charts and nursing documentation. I assisted in a chart audit and I was frightened at what we didn' t find, a lot of missing information that JCAHO looks at during our yearly visits. There was lack of specific information for instance a pain care plan, their wasn't a specific pain scale used with the patient, well perhaps there was,but it was not in the care plan,so as we know,it did not happen.

Czar, P. & Hebda, T. (2013) The role of standardized terminology and language in informatics. Handbook of informatics for nurses & healthcare professionals(5th Ed). Saddle River, NJ. Pearson.