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.

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 on or before Day 3 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

Readings

  • American Nurses Association. (2015). Nursing informatics: Scope & standards of practice (2nd ed.).Silver Springs, MD: Author.
    • “Metastructures, Concepts, and Tools of Nursing Informatics”

      This chpater explores the connections between data, information, knowledge, and wisdom and how they work together in nursing informatics. It also covers the influence that concepts and tools have on the field of nursing.

  • McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (2nd ed.). Burlington, MA: Jones & Bartlett Learning.
    • Chapter 6, “Overview of Nursing Informatics”

      This chapter defines the foundations of nursing informatics (NI). The authors specify the disciplines that are integrated to form nursing informatics, along with major NI concepts.

    • Chapter 7, “Developing Standardized Terminologies to Support Nursing Practice”

      This chapter explores the need for consistent nursing terminology. The authors also detail the different approaches to developing terminology.

  • Brokel, J. (2010). Moving forward with NANDA-I nursing diagnoses with Health Information Technology for Economic and Clinical Health (HITECH) Act Legislation: News updates. International Journal of Nursing Terminologies & Classifications21(4), 182–185.
    Retrieved from the Walden Library databases.

    In this news brief, the author describes the initiatives that NANDA-I will implement to remain abreast of the HITECH legislation of 2009. The author explains two recommendations for the federal government’s role in managing vocabularies, value sets, and code sets throughout the health care system.

  • Matney, S., Brewster, P. J., Sward, K. A., Cloyes, K. G., & Staggers, N. (2011). Philosophical approaches to the nursing informatics data-information-knowledge-wisdom framework. Advances in Nursing Science34(1), 6–18.
    Retrieved from the Walden Library databases.

    This article proposes a philosophical foundation for nursing informatics in which data, information, and knowledge can be synthesized by computer systems to support wisdom development. The authors describe how wisdom can add value to nursing informatics and to the nursing profession as a whole.

  • Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? OJIN: The Online Journal of Issues in Nursing13(1). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursingLanguage.html

    The author of this article provides justification for the use of a standardized nursing language, which will be necessary for incorporating electronic documentation into the health care field. The author defines standardized language in nursing, describes how such a language can be applied in a practice setting, and discusses the benefits of using a standardized language.

  • Westra, B. L., Subramanian, A., Hart, C. M., Matney, S. A., Wilson, P. S., Huff, S. M., … Delaney, C. W. (2010). Achieving “meaningful use” of electronic health records through the integration of the Nursing Management Minimum Data Set. The Journal of Nursing Administration40(7–8), 336–343.
    Retrieved from the Walden Library databases.

    This article explains the nursing management minimum data set (NMMDS), which is a research-based minimum set of standard data for nursing management and administration. The article describes how the NMMDS can be used to minimize the burden on health care administrators and increase the value of electronic health records within the health care system.

Media

  • Laureate Education, Inc. (Executive Producer). (2012a). Data, information, knowledge, and wisdom continuum. Baltimore, MD: Author.
    McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (2nd ed.). Burlington, MA: Jones & Bartlett Learning. (p. 98, Chapter 6, Figure 6)

    The continuum of data, information, knowledge, and wisdom is used in the health care field to describe discrete levels of understanding related to patient care and decision making. This video provides an overview of the continuum from data to wisdom.

Optional Resources

  • Truran, D., Saad, P., Zhang, M., & Innes, K. (2010). SNOMED CT and its place in health information management practice. Health Information Management Journal39(2), 37–39.
    Retrieved from the Walden Library databases.
  • Brown, B. (2011). ICD-10-CM: What is it, and why are we switching? Journal of Health Care Compliance13(3), 51–79.
    Retrieved from the Walden Library databases.
 

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