NURS 6411:Week 11: Standardized Terminologies Applied to Health Care Essay Assignment Paper

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NURS 6411:Week 11: Standardized Terminologies Applied to Health Care Essay Assignment Paper

NURS 6411: Information and Knowledge Management | Week 11

How important is it to use standardized terminologies and encourage collaboration in health care organizations?

Imagine you are treating a patient who is expressing a problem with breathing. You carefully record in his chart that he has shortness of breath. After the doctor performs her exam, she states that the patient is suffering from dyspnea. When you discuss the case with a fellow nurse, she remarks that she has seen such cases before and it is certainly caused by abnormal breathing patterns. All three diagnoses actually refer to the same condition. The real problem occurs when the information is entered into a database. Which term should be used? Later, if you are trying to identify patients with similar conditions, would you miss some because of the varying terminologies?

Similarly, multiple health care organizations can each have specific data about a patient or illness, but unless the data terminology is standardized, the value of the database system is limited. This standardization is conducive to improving patient care and reinforcing productive communication between nurses, doctors, and other health care personnel.

This week, you familiarize yourself with the importance of standardized terminologies for data storage and retrieval. You also focus on the relationship between clinical information systems and standardized terminologies in database design.

Learning Objectives

Students will:

• Assess the use of standardized terminologies in databases and clinical information systems
• Analyze the importance of standardized terminologies for data retrieval

Learning Resources

Required Readings

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Hammond, W. E., Jaffe, C., & Kush, R. D. (2009). Healthcare standards development: The value of nurturing collaboration. Journal of AHIMA, 80(7), 44–50. Retrieved from http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_043995.hcsp?dDocName=bok1_043995

The authors of this article explore the effect that differing standards have on the health care field and how collaboration can help move standardization processes forward.

Dontje, K., & Coenen, A. (2011). Mapping evidence-based guidelines to standardized nursing terminologies. Computers, Informatics, Nursing, 29(12), 698–705.

This article explores ways to standardize data terminology and data storage for increased diagnostic and treatment efficiency. The authors evaluate the utilization of standardized nursing terminologies and evidence-based guidelines with depression cases to pinpoint efficient implementation techniques and techniques that can still be improved.

Hayrinen, K., Lammintakanen, J., & Saranto, K. (2009). Evaluation of electronic nursing documentation—nursing process model and standardized terminologies as keys to visible and transparent nursing. International Journal of Medical Informatics, 79(8), 554–564.

The authors of this article discuss the relationship between nursing processes and the development of more complete and comprehensive electronic health records (EHRs). In addition, they evaluate the motivations behind standardizing data for universal comprehension and application.

Thoroddsen, A., Ehnfors, M., & Ehrenberg, A. (2011). Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records. Computers, Informatics, Nursing, 29(10), 599–607.

Retrieved from the Walden Library databases.

 

In this research study, the authors performed audits of patient records to examine issues regarding documentation terminologies in patient care. The study revealed the need for standardized nursing terminologies and the role of these terminologies in improving the accuracy of evidence-based diagnoses.

Frisher, M., Short, D., & Bashford, J. (2010). Determining patient characteristics for decision analysis support systems using anonymized electronic patient records. Health Informatics Journal, 16(1), 49–57.

This article reports on a study conducted with stroke patients that examined how decision analysis support systems can be applied. The authors discuss how evidence-based consultations of patients and data analysis can improve decision making.

Huryk, L. A. (2012). Information systems and decision support systems. American Journal of Nursing, 112(1), 62–65.

The Health Information Technology for Economic and Clinical Health (HITECH) Act has encouraged the implementation of technologies in evidence-based practice, diagnostics, and research. One result of this is the growing reliance on decision support systems in patient care. The author of this article examines how the nursing field and curricula are adapting to meet this change in practice.

Ensuring data integrity. (2009). Nature Neuroscience,12(10), 1205.

Retrieved from the Walden Library databases.

 

This article explores methods that health care organizations can employ to ensure the integrity of collected and stored data.

Required Media

Laureate Education, Inc. (Executive Producer). (2012). Standardizing nomenclature. Baltimore. Baltimore, MD: Author.

Note: The approximate length of this media piece is 6 minutes.

Roy Simpson describes the importance of standardizing clinical language using nomenclatures, or methods of coding clinical information.

Discussion: Standardized Terminologies in Health Care Databases

Have you ever traveled abroad and asked for directions from someone who did not speak your own language? Perhaps you unsuccessfully attempted to use Google Translate or tried gestures and hand signals to communicate your request. The ability to communicate in the same language greatly increases the likelihood of shared understanding.

In health care, having a standard terminology facilitates the flow of information. Just as two people who speak different languages have difficulty understanding one another, so will two databases that utilize differing sets of terminologies. Standardized, shared terminologies enable database systems to effectively communicate.

To prepare:

• Review this week’s Learning Resources focusing on the significance of standardized terminologies in health care settings. Consider how standardized terminologies are important in the development and use of databases and clinical information systems.
• Explore the websites of major health care organizations to determine their recommendations on acceptable standardized terminologies.
• Determine the standardized terminologies currently used by your health care organization (or one with which you are familiar).
• Consider the standard terminologies (recommended by a major medical organization or based on your experiences) you would like to see incorporated into your organization’s databases and clinical information systems. What would be the benefit of using these particular standards? How might this impact the quality of the information retrieved from databases within your organization?

By Day 3

Post a description of at least one standardized terminology that is recommended by a major health care organization. Assess how or if this terminology is incorporated into your organization’s databases and clinical information systems. Identify at least one additional standardized terminology you would like to see incorporated into the organization’s databases. Analyze the importance of incorporating this terminology and how this could impact the quality of the data retrieved from the databases. Justify your response.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days using one or more of the following approaches:

• Ask a probing question, substantiated with additional background information, evidence, or research.
• Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
• Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
• Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

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