Week 3 Discussion Standardized Coding System

Week 3 Discussion
Standardized Coding System
The use of a standardized nursing language for documentation of nursing care is fundamental to the nursing profession and to the bedside nurse (Rutherford, 2008). Communication is a vital key in the nursing practice. A standardized nursing language is used by nurses to communicate nursing care and it is important that this can be communicated accurately among nurses and other health care providers (Ruthford, 2008). Nurses use standardized nursing languages because it helps for better communication among nurses and other health care providers, it increases the visibility of nursing interventions, it improves patient care, enhances data collection and makes documentation less complex, it allows communication between nurses to remain uniform regardless of location of the health care organization, and it facilitates assessment of nursing proficiency (Ruthford, 2008). Therefore, with the increase use of technology and use of electronic health records (EHRs) in health care facilities, standardized nursing language proves to be much needed for documentation to be clear, concise, accurate, and most importantly easily understood by all health care providers accessing the documentation or involved in the patient care.
Can this Standardization be limited to specialty area or be used across all nursing practice?
It is best that nursing standardized language be used across all nursing practice in order to minimize confusion and ensure clarity, and effective delivering of quality patient care. I believe that if standardization is limited to a specialty area, errors could occur since other providers involved in a patient’s care, who are not in the same specialty (example, a psychiatrist referring a psych-patient to a cardiologist) may encounter difficulties when accessing patient records could confuse one standardized language to mean something totally different. This could easily lead to confusion, errors, and the goal to provide quality patient care could be hindered. Apparently, there is a need in nursing, as in other areas of health care, for a means to resolve any problems subsequent from the use of separate terminologies; what I mean is there is a need for a standardized language across all nursing practice (Hardiker, Hoy, & Casey, 2000). Having a standardized nursing language will definitely enhanced quality patient care, by ensuring that terminologies are developed using tried and tested methodologies, Reduced effort, by avoiding reinvention of the wheel, guarantee greater consistency and a mechanism for union between terminologies, and ensure compatibility, by confirming the integrity of data collected across different source systems (Hardiker, Hoy, & Casey, 2000, p. 524).
Examples of standardization in my specialty/area of practice and articles that support this
According to the Texas Education Agency (2012), “healthcare professionals must have a comprehensive medical vocabulary in order to communicate effectively with other health professionals. They should be able to use terminology related to psychiatry when discussing medications” (Texas Education Agency, 2012). In psychiatric nursing, terminology is extremely important and useful for nurses and other health care providers while delivering care to patients with mental health illnesses. For example, during documentation, it is very common to see terminologies like SI/HI/AVH which means Suicide Ideation, Homicidal Ideation, and Auditory/Visual Hallucination. Most important, when my unit present with an severely aggressive patient who is refusing all medications, whether in the psychiatric unit or in the emergency department, when a health care provider states “Start order for B52 cocktail/Injection” it understood to mean Benadryl (either 25 or 50mg; MD will specify), Haldol 5mg, and Ativan 2mg. Also, another terminology used on my unit is the “Banana Bag” whether this terminology is used on the psych floor or the emergency unit or medical floor, nurses know that it is a bag of IV fluids containing vitamins and minerals (thiamine, folic acid, and magnesium sulfate), which are usually used to correct nutritional deficiencies or chemical imbalances in the human body (Sharabun, 2016). This also shows you how important it is for standardized nursing language/terminology be used across all nursing practice.
In conclusion, a standardized nursing language have improved communication with other nurses, health care professionals, and administrators of the health institutions (Ruthford, 2008). According to the Institute of Medicine, “The Electronic Health Record (EHR) in practice settings has accelerated the need for nursing to communicate its practice within the structure of the electronic format. The integration of standardized nursing language into the patient record offers nurses an opportunity to describe the focus of their practice through the identification of nursing diagnosis, interventions and outcomes” (Jones, Lunney, Keenan, & Moorhead, 2010, p. 253). The goal is to develop a lexis that could meet all the needs of all nurses and health care providers for better communication and delivering of proper patient care. Terminologies symbolize, at best, clarifications for effective communication in nursing care and create standardization in various health care organizations (Hardiker, Hoy, & Casey, 2000). Therefore, is an opportunity now to apply the standardized nursing language in order to further nursing practice, and to validate improvements in patient outcomes through nursing care (Strudwick, & Hardiker, 2016).

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Reference
Hardiker, N. R., Hoy, D., & Casey, A. (2000). Standards for nursing terminology. Journal of American Medical Informatics Association, 7(6), 523-528. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC129660/pdf/0070523.pdf
Jones, D., Lunney, M., Keenan, G., & Moorhead, S. (2010). Standardized nursing languages: Essential for the nursing workforce. Annual review of nursing resources, 28(1), 253-294.
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 3(1), doi:10.3912/OJIN.Vol13No01PPT05
Sharabun, M. (2016, August 14). What’s a Banana Bag. Retrieved from http://www.pharmacytimes.com/resource-centers/vitamins-supplements/whats-a-banana-bag
Strudwick, G., & Hardiker, N. R. (2016). Understanding the use of standardized nursing terminology and classification systems in published research: a case study using the International Classification for Nursing Practice. International Journal of Medical Informatics, 94(1), 215-221. https://doi.org/10.1016/j.ijmedinf.2016.06.012
Texas Education Agency. (2012). Psychiatric Terminology. Retrieved from http://data.cteunt.org/content/files/health/medical-terminology/unit-15-diagnostic-procedures-and-pharmacology/psychiatric/15-psychiatric.pdf

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