Feb 23, 2024 NR 361 Week 3: Standardized Terminology and Language in Informatics
NR 361 Week 3: Standardized Terminology and Language in Informatics
NR 361 Week 3: 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.
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Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.
Hello Professor Graham and Classmates,
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.
What is the impact of Centers for Medicare and Medicaid Services (CMS) payment denial on the healthcare system?
What are the implications for our nursing practice related to use of standardized terminology for documentation?
How do evidence-based practice guidelines impact patient outcomes and necessitate improved practice care?
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NR 361 Week 3 Standardized Terminology and Language in Informatics
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Also Check Out: NR 361 Week 4: Your Patient Has a Personal Health Record . . . Now What?
With electronic health records on the rise due to advancement in information technology, the quality of patient care is expected to improve. Electronic documentation reduces charting duplication and the inefficiency that results from paper charting, it also secures and improves communication between nurses and the healthcare team (Hariyati et al., 2020).
Usability in health information technology is referred to as the quality of the user’s experience with a computer related program; the effectiveness, efficiency and satisfaction of the user are key terms (Hebda, Hunter & Czar, 2019). It is important for informaticists to create and purchase programs and softwares that are user friendly. Poor usability can result in minor to major issues, such as treatment and decision delays to jeopardizing patient safety during a medication pass (Hebda, Hunter & Czar, 2019). The post acute care facility I work at did not invest in a user friendly EHR, American HealthTech. The book gave a great example in how eMARs can create patient safety issues due to the inability of nurses to efficiently organize medications or see missed medications for their patients. I’ve been in urgent situations where I needed to quickly access a list of a patient’s medications that was taken within the last 24 hours and I was unable to do so because of the inability of the software to expand the medication list on my laptop screen. Rather I needed to opt for a print option and do a print preview to get the full view of the medications. The extra steps required can cause frustration in emergent situations especially when the internet connection can be slow at times. The eMAR also did not allow for viewing medications by time blocks, so during medication pass I see a full list of my patients’ medications that I would need to administer for my entire shift, and it is not color coded, which can be overwhelming for a new user. With time and practice, one can adjust to using this EHR but the usability is a different story.
References
Hariyati, R. T. S., Hamid, A. Y., Eryando, T., & Hasibuan, Z. A. (2020). Usability and satisfaction of using electronic nursing documentation, lesson-learned from new system implementation at a hospital in Indonesia. International journal of healthcare management, 13(1), 45–52. https://doi.org/10.1080/20479700.2018.1504387Links 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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