The quality of care in today’s complex healthcare settings depends on the availability and accuracy of patient information (McCormick et al., 2015). As such, it is important to consider the role of formal nursing nomenclature and its relationship to data concepts.
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Planning and documenting nursing care is a challenging process since the accuracy of information is essential for proper medical care. Before formal nursing nomenclatures were established, a variety of different terms could be used by various medical facilities to describe the same type of care (Rutherford, 2008). Nursing nomenclatures were introduced to establish a formal system of medical terms. Therefore, standardized terms used in planning and documenting nursing care allowed providers to reduce confusion introduced by various terminology and, therefore, improve the quality of care.
Terms used in planning and documenting nursing care are directly connected with such data concepts, as data elements, data requirements, and data set. Nursing nomenclature provides an identifying name and specified value types to valid medical terms, which act as data elements. Data elements, or medical terms, are included in a larger framework called data set, or nursing nomenclature. Nursing nomenclature also provides a set of rules and procedures or an input-data structure that describes the way new terms or data elements can be included in the data set. As such, is provides data requirements for practitioners to rely on.
Formal nursing nomenclature acts as a framework that enhances data collection and allows practitioners to effectively manage information by establishing data requirements and standardizing data outputs. Standardized outputs have multiple benefits, including “better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care” (Rutherford, 2008).
Nursing terms used in my work setting clearly and comprehensively represent nursing care and nursing practice. Even though no formal nomenclature is used, nursing terms allow for an efficient shared understanding of relevant medical information between various clinicians.
The main goal of nursing terms is to aid intradisciplinary and interdisciplinary communication in a clinical setting (Keenan, Yakel, Tschannen, & Mandeville, 2008, p. 175). Efficient communication is the foundation of high-quality care. The complexity of modern healthcare settings means that if a clinician does not have the right information at the right time, they cannot make an informed decision about the treatment. As such, nursing terms aid the process of documentation and recordkeeping by providing framework nurses and other medical personnel can use to make informed decisions about the patient and their treatment plan.
Nursing terms used in my work setting comprehensively address the issue of patient safety. Medical errors have been thoroughly studied as one of the major factors contributing to unfavorable outcomes. A research paper by Pascale Carayon, et al. uses the human factors system approach to addressing the issue of healthcare quality and patient safety. The researchers evaluate the effects of work systems design on the quality of care and conclude that while multiple system elements have implications for patient safety, the ambiguity in current patient care guidelines affect the quality of care (Carayon et al., 2014). Nursing terms used in my work setting resolve the ambiguity by providing comprehensive terminology for various medical terms.
Such tools as nursing terms are vital for communication and proper healthcare delivery in a clinical setting. Current terminology established in my work setting fully reflects the scope of work performed.
Carayon, P., Wettereck, T., Rivera-Rodriguez, A., Hundt, A., Holden, R., & Gurses, A. (2014). Human factors systems approach to healthcare quality and patient safety. Applied Ergonomics, 45(1), 14-25. Web.
Keenan, G., Yakel, E., Tschannen, D., & Mandeville, M. (2008). Chapter 49. Documentation and the Nurse Care Planning Process. Web.
McCormick, K., Sensmeier, J., Dykes, P., Grace, E., Matney, S., Schwartz, K. & Weston, M. (2015). Exemplars for advancing standardized terminology in nursing to achieve sharable, comparable quality data based upon evidence. Online Journal of Nursing Informatics (OJNI), 19(2), n.p. Web.
Rutherford, M. (2008). Standardized Nursing Language: What Does It Mean for Nursing Practice? OJIN: The Online Journal of Issues in Nursing, 13(1),1-11. Web.