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Whenever one person visits a clinic and receives medical care, much documentation and paperwork is involved. In many cases, a single patient is treated and assessed by several different healthcare professionals. These professionals need to communicate with one another regularly. This is why the efficiency and clarity of their communication are highly important. To standardize terminologies used by healthcare professionals, many coding systems are in place.
Standardized Coding in Healthcare
As information technologies became more and more popular as instruments used in healthcare, they started to stimulate changes in the models of care (The Office of the National Coordinator for Health Information Technology, 2017). Communication is one of the spheres affected by the integration of health IT the most. Daily, nurses receive, pass, and accumulate a great amount of valuable professional information. If this information is not documented and stored properly, it could be distorted or lost (The Office of the National Coordinator for Health Information Technology, 2017). Standardized coding and terminologies are tools that help improve communication and keep the information intact.
The Importance of Using Standardized Terminologies
As medical professionals, nurses have always been involved in the collection of valuable data in the form of atomic-level elements of assessments, medical statistics, patient satisfaction measures, healthcare payments, and reimbursements, to name a few (McGonigle & Mastrian, 2018). The use of standardized terminologies and coding allows nurses to store this information for further use by professionals of other specializations. This way, the required data about patients’ health and spent resources can be communicated quickly, effectively, and safely. This is why such methods are vital in contemporary healthcare powered by information technologies and fast electronic communication.
One of the major benefits that can be achieved using standardized terminologies and coding systems is continuity of care. This concept stands for the logical and coherent implementation of care delivered by several providers with different specialties (Mendes, Gemito, Caldeira, Serra, & Casas-Novas, 2017). Continuity is particularly applicable in cases of chronic disease and complex health conditions where multidisciplinary teams of care providers treat one patient over a lengthy period. Continuity helps to cut costs due to the consistency of care (American Nurses Association, 2015).
Why Nurses Need to Use Standardized Terminologies
The use of standardized terminologies and coding is a necessary element for medical research. In other words, the data collected by nurses can be accessed for research and planning in such spheres as epidemiology, public health, cost-saving, and budgeting among others. Moreover, as it was mentioned previously, nurses are often a part of multidisciplinary teams of care providers working on a single patient. The use of a standardized language for communication can ensure efficiency and coherence of care thus cutting costs and improving productivity and patient experience. These are the points I would make when explaining the need for standardized terminologies to nurses who do not know why they are used.
Personal Practice Experiences
North American Nursing Diagnosis Association (NANDA) is the interface terminology used in my organization. This is an international terminology that is widely used all around the globe. Also, it applies to a variety of nursing specializations (The Office of the National Coordinator for Health Information Technology, 2017). The terminology or coding system needs to be universal because this is the quality that makes it the most effective for various settings and organizations. Differently put, it is preferable that a clinical terminology is useful across all nursing practice and not just one specialty.
American Nurses Association. (2015). Nursing informatics: Scope & standards of practice (2nd ed.). Silver Springs, MD: American Nurses Association.
McGonigle, D., & Mastrian, K. (2018). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.
Mendes, F., Gemito, M., Caldeira, E., Serra, I., & Casas-Novas, M. (2017). Continuity of care from the perspective of users. Ciência & Saúde Coletiva, 22(3), 843-855.
The Office of the National Coordinator for Health Information Technology. (2017). Standard nursing terminologies: A landscape analysis. Web.