NR 361 Week 3: Standardized Terminology and Language in Informatics (graded)

NR 361 Week 3: Standardized Terminology and Language in Informatics (graded)

NR 361 Week 3: Standardized Terminology and Language in Informatics (graded)

One standardized terminology that is very crucial in healthcare is the term Interoperability. Hebda, Hunter, and Czar define interoperability as “the ability to exchange information across systems” (Hebda, Hunter, & Czar, 2019, p. 156). I believe this especially important when caring for patients in a hospital setting, because so many members of the healthcare team need to document on the care provided. Many disease processes require multidisciplinary teams to treat and care for those patients. One example of this is the care for a stroke (CVA) patient. Once on an inpatient unit, members of the care team include attending physician, Neurology physician, nurses, pharmacist, physical therapist, occupational therapist, speech language pathologist, case manager, and possibly operating room nurses and Neurosurgeons or interventional radiology physicians and nurses (Clarke & Foster, 2015). At my hospital for example, all of these disciplines do not use the same program for charting. My hospital uses Cerner as their EMR system, but each discipline uses their own version. PT, OT, and SLP all use different forms for their charting, which are all accessible for nursing staff to view, but it is not as streamline as one would hope. The forms that PT, OT, and SLP use all include ICD coding, that us nurses are not taught to identify. OR and IR nurses use different charting programs that do not easily cross-over to inpatient nursing documentation. For this reason, many nursing interventions done in the OR or IR are not properly documented, such as new IV placements and indwelling catheter insertions. I believe interoperability in healthcare informatics definitely has room for improvement. The shift to all electronic medical records has greatly enhanced the outcomes for patients. Making all this documentation easy to read and more streamline would help inpatient nurses like me to connect the dots when doing research on my patients. Understanding what each discipline is doing will help the healthcare team members work better together.

References

Clarke, D. J., & Foster, A. (2015). Improving post-stroke recovery: the role of the multidisciplinary health care team. Journal of multidisciplinary healthcare, 8, 433-442. https://doi.org/10.2147/JMDH.S68764

Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.

I would like to talk about usability in my practice. Usability simply explained by the ability to be used. “Good usability is critical for the adoption and safe use of health-information products…Concepts about usability guide informaticists in creating and purchasing technologies that users find effective, efficient, and satisfying to use.” (Hebda, 2019, P. 168.) Poor usability can result in decrease in productivity, errors, delayed treatment and decision, user frustration, underutilization of systems, deinstallations, and need for extra support. (Hebda, 2019)

In my opinion, electronic clinical documentation can improve the usability to reach the goal of effectiveness, efficiency, and satisfaction. “Evidently, the implementation of electronic clinical documentation is essential to enhance the provision of safe, ethical, and effective nursing care. Previous research presented that electronic documentation improved the completeness, quality of nursing documentation and quality of care. Another benefit of electronic documentation are nurses no longer have to waste time consulting with one another, trying to decipher someone’s dreadful handwriting, and fewer errors related to misinterpreted orders should follow.” (Harivati&Tutik, 2020) Point Click Care (PCC) was introduced to my rehab center two years ago. PCC absolutely plays a critical role to improve efficiency of nursing care. For example of the assessment of bowel movement and dehydration. With paper charting, I need to review every page for each patient to see when they have bowel movement and in&out to figure out if they need treatment. It normally took me about 30 minutes for 20 patients. With PCC, I just need to search key words “bowel movement” and sort result by patient’s name or room number or anything that is convenience for me. In this way, I just need up to 5 minutes to find the result.

References

Hariyati, Rr Tutik Sri, et al. “Usability and Satisfaction of Using Electronic Nursing Documentation, Lesson-Learned from New System Implementation at a Hospital in Indonesia.” International Journal of Healthcare Management, vol. 13, no. 1, Apr. 2020, pp. 45–52.

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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Hi Professor and Class, 

     Standardized terminology is significant in the healthcare setting as it allows for proper communication among healthcare workers. It ensures that the language or terms being used in the healthcare setting is understood by all members of the healthcare team. Of the topics listed, I would like to elaborate on the North American Nursing Diagnosis Association or NANDA. My understanding and knowledge of NANDA expanded throughout nursing school. Utilizing NANDA was emphasized for assignments such as patient care plans. Based on the patients I would encounter during clinicals, I would have to write a care plan including the patient’s clinical diagnosis and more importantly, the nursing diagnosis. 

A nursing diagnosis differs from a clinical diagnosis such as hypertension in that it is a clinical judgement based on the nurses’ assessment about the patient or family and the responses to the actual clinical problem (Hebda, Hunter, & Czar, 2019). It is further classified into 13 different domains consisting of common problems the patient may be experiencing as a result of the clinical diagnosis. As I was taught in nursing school, a complete nursing diagnosis includes a description, a definition, and a defining characteristic consisting of common signs and symptoms to aid nurses in choosing the correct diagnosis (Hebda, Hunter, & Czar 2019). 

Utilizing nursing diagnosis has a positive impact on my nursing practice because it becomes useful to look at the bigger picture. It is always important to take into account the clinical diagnosis in order to treat the patient. However, it is equally as important to recognize how this clinical diagnosis is impacting the patient personally and impacting one of the 13 domains. One of the many strengths of utilizing a nursing diagnosis is “Increased continuity of nursing care among members of the nursing care team during client handoffs when shifts change” (Hood, p. 169). I still remember in nursing school when giving a hand off report to the oncoming shift, I was taught to mention the nursing diagnosis to the oncoming shift. This helps  ensure that the plan of care is the same even if the nurse is not. The patient can also be a part of this plan and assist in adding more diagnosis if needed. Overall, utilizing nursing diagnosis has had a positive impact in my nursing practice even as a nurse today.  

References 

Hebda, T., Hunter, K., & Czar, P. (2019). Handbook of informatics for nurses & healthcare professionals (6th ed.). Pearson.

Hood, L.J. (2017). Leddy & Pepper’s professional nursing (9th ed.). Pearson