Standardized Coding Systems As a result of the fragmented nature of the health care system, professionals in various specialty areas of medicine have developed their own unique sets of terminology to communicate within that specialty. In the past, limited attention has been given to codifying practices in order for them to be understood and utilized across disciplines or through different information technology systems. The implementation of a federally mandated electronic medical records system, therefore, poses a challenge to nursing professionals and others who must be prepared to utilize standardized codes for the new system. Why are coding standards important for promoting consistent, high-quality care? According to Rutherford (2008, para. 15), Improved communication with other nurses, health care professionals, and administrators of the institution in which nurses work is a key benefit of using a standardized nursing language. In this Discussion you consider the reasoning behind and the value of standardized codification. To prepare Review the information in Nursing Informatics: Scope and Standards of Practice. Determine which set of terminologies are appropriate for your specialty or area of expertise. Reflect on the importance of continuity in terminology and coding systems. In the article, Standardized Nursing Language: What Does It Mean for Nursing Practice? the author recounts a visit to a local hospital to view its implementation of a new coding system. One of the nurses commented to her, We document our care using standardized nursing languages but we dont fully understand why we do (Rutherford, 2008, para. Consider if standardization can be limited to a specialty area or if one standard language is needed across all nursing practice. Then, identify examples of standardization in your own specialty or area of expertise. Conduct additional research using the Walden Library that supports your thoughts on standardization of nursing terminology. By Day 3 Post an explanation of why nurses need to document care using standardized nursing languages and whether this standardization can be limited to specialty areas or if it should be across all nursing practice. Support your response using specific examples from your own specialty or area of expertise and using at least one additional resource from the Walden Library. *I need a response to this discussion with at least 3 references by 12/11/2018. Two of the references have to be from the required reading references listed below. *List of required references to use for this assignment: American Nurses Association. (2015). Nursing informatics: Scope & standards of practice (2nd ed.). Silver Springs, MD: Author. Metastructures, Concepts, and Tools of Nursing Informatics McGonigle, D., & Mastrian, K. G. (2018). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones and Bartlett Learning. Chapter 6, History and Evaluation of Nursing Informatics Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? OJIN: The Online Journal of Issues in Nursing, 13(1). Retrieved from https://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursingLanguage.html Laureate Education (Producer). (2012a). Data, information, knowledge, and wisdom continuum. Baltimore, MD: Author. McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (2nd ed.). Burlington, MA: Jones & Bartlett Learning. (p. 98, Chapter 6, Figure 6) Brokel, J. (2010). Moving forward with NANDA-I nursing diagnoses with Health Information Technology for Economic and Clinical Health (HITECH) Act Legislation: News updates. International Journal of Nursing Terminologies & Classifications, 21(4), 182185. Westra, B. L., Subramanian, A., Hart, C. M., Matney, S. A., Wilson, P. S., Huff, S. M., Delaney, C. W. (2010). Achieving meaningful use of electronic health records through the integration of the Nursing Management Minimum Data Set. The Journal of Nursing Administration, 40(78), 336343.
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