Applying Standardized Terminologies in Practice
Standardized nursing terminologies provide many benefits to patients, facilities and nursing professions. Health Information Technology (HIT) assist facilities and team members to improve the quality of healthcare by communicating and coordinating the efficiency, accuracy, and effectiveness of patient care. Thede and Sewell (2010) stated that three tasks are involved in standardizing nursing terminology so that it can be used in electronic databases: identifying the necessary data elements, developing the terminology, and classifying the terminology and assigning codes. The use of standard terminologies within the Electronic Healthcare Records (EHR) validates nursing care by communicating their
Hi Prof. Antoisnne, It is imperative that the HIM professional establish data standards to ensure data quality and consistency. Establishing data standards would help to ensure patient safety, consistent delivery of health care services, plan coordination of care, and standardize healthcare reporting. Essentially, data standards are needed to assess the quality and consistency of collected data. Organizations need HIM professionals to familiarize themselves with these standards to create an organizational standardized data dictionary, format electronic health records, and standardize the exchange of health information across the continuum for general data management and to ensure the integrity and reliability of gathered data.
The resources above expanded on knowledge concerning the definition, evolution, proposed outcomes, research and the technology of meaningful use of the electronic health record. Nursing administrators, staff nurses, and nursing informaticists all perform an essential role in achieving meaningful use of the electronic medical record to improve patient care. Certain authors referenced other authors proving that the health information technology field is indeed a tightknit community. The resources were well written from highly credentialed authors and were, for the most part, easy to comprehend. All of these articles were written for the nursing professional with the exception of resource
In studying Registered Nursing one will find that they have to be compassionate and want to care for others. Registered Nurses assist physicians with suffering patients of any medical condition. They help to decide the patient’s medicine, treatment, recovery, and educate the them and their families on post-medical treatment. They need to have bedside manner, and be able to prepare patients for surgery. Registered Nursing careers range anywhere from critical care, oncology, mental health, to an everyday school nurse.
The Omaha System (OS) is a research-based nursing standard, developed in Omaha Nebraska (deBloc, 2011). OS is an internationally known standardized language (SL) that focuses on homecare and public health settings that has been proven to have the potential to accurately represent clinical data in Electronic Health Records (Topaz et al., 2012). OS is a system which contains hierarchies and terms. It is a standardized
Then the HHS decided to establish security and privacy requirements for patient health information; standards for electronic health care transactions; creating the national identifiers (for providers, health insurance providers, employers, patients); encouraging the widespread use of electronic data interchange in healthcare system. All of these standardizations, became known as Administrative Simplification, which has Rules that addresses specific issues in order to create basic standards for states to follow (and improve
This includes creating, managing and following patient data. The American Health Information Management Association (AHIMA) defines information governance as “an organization wide framework for managing information throughout its lifecycle and for supporting the organization’s strategy, operations, regulatory, legal, risk, and environmental requirements.” In today’s healthcare system, it is more important than ever to know and understand how healthcare information is created, transferred and used. Due to the development of systems such as electronic health records and clinical decision support systems it is important that health information maintains its reliability and validity throughout its
The authors also showed how HCPCS codes are used when healthcare providers provides education to the patient and/or their family. Gatlin, Mburu, Jackson, and Hunt briefly discuss International Classification of Disease 10th edition (ICD-10) and how healthcare providers have to adopt to a completely new alphanumeric language. In conclusion, Gaitlin, Mburu, Jackson, and Hunt has thoroughly discuss HCPCS and how important it is in healthcare billing. The authors provided two examples on HCPCS and CPT codes are used to help ensure accurate documentation for billing.
As nurses, we continue to gain knowledge and skills within our area of practice. We use theories to help us build concepts or ideas in gathering information, explaining relationships and demonstrating experiences of development. Theories vary in their level of abstraction and scope. Nursing theories are beneficial in helping us to understand, organize our thoughts and influence practice and research. Nursing theory has three distinct types to describe the level of abstraction:
“Concept clarification is an important step in developing useful and useable knowledge in nursing science.” (Tofthagen, 2010). Within the home health field of nursing one of the major and most significant concepts is team work. Simply stated, concept analysis incorporates a method or approach by which concepts that are of interest to a discipline are examined in order to clarify their characteristics or attributes” (Cronin, 2010). Within a home health care team there are Registered Nurses, Physical Therapists, Home Health Aides, Medical Social Workers, Managed Care Coordinators, and Clinical Managers.
Social media platforms continue to change the healthcare landscape by allowing for users to see a variety of information and points of view. Social media can be used for information and education, marketing, recruiting, and news updates. Healthcare organizations and consumers can utilize social media to improve health and knowledge. Social media can also be used for research, disease tracking, and to monitor trends. This paper discusses the controversial public health topic of abortion and what people are saying regarding it on Twitter.
I will summarize each outcome for the Nursing Informatics specialty. For the intent of this paper I will use outcome and competency interchangeably. The first outcome means the ability to gather healthcare information across the continuum of care; combine and utilize the information gathered to develop a process. Finally execution of that process to evaluate its ability to improve the quality of the healthcare environment. Healthcare managers are constantly assessing patients and collecting information.
The term six research theory course, NURS 495, emphasized the importance of nurse leadership and how nurses can influence positive changes in health care delivery to patients with chronic illness. It also explored the contradictions that exist in nursing practice and encouraged the students to develop a critical and pragmatic approach to client care. The co-requisite clinical course, NURS 499, integrated nursing theory and current best practice on an acute care nursing unit at Medicine Hat Regional Hospital. In this consolidated learning analysis, I will explore a nursing practice event that will illustrate the major issues surrounding the treatment of competing mental health comorbidities in a patient with hoarding behaviors.
What does nursing mean to me? Nursing means helping people heal, meeting their needs while they are in your care, listening to concerns, protecting them from harm, and educating them how to care for themselves while treating them with dignity, compassion and respect and giving of yourself to the care of people and community. It is having compassion for people and their health and being a humanitarian, making sure they receive the best care possible. Nurses must also treat families of patients with kindness, realizing they are going through a stressful situation also. Nursing is a responsibility to provide the best care regardless of the patient’s age, race, religion, sex, disability, ethnicity, sexual orientation, or their past.
The baccalaureate prepared nurse role is crucial in ensuring the successful implementation of quality management in healthcare. The major role of healthcare professionals such as nurses, doctors, and physicians is the delivery of high-quality patient care and safety. However, studies show that some factors that contribute to the low-quality patient care and safety include medical errors, adverse drug events, and negligence of health care providers. The baccalaureate prepared nurse has the responsibility of improving patient outcomes by taking part in quality management processes in the healthcare.
Nursing Theorists and their Theory 1.Florence Nightingale- Nightingale’s theory of the Environment is mainly focused on the environment, she believed that, the environment has a great importance that can be used to improve and encourage healing. With proper ventilation, clean air, lack of noise , proper lighting, and adequate elimination of waste. Are a few factors she believed and can be observed and maintained. 2.Sister Calista Roy- Roy’s Theory is based on, in which the individual views biopsychosocial being, in which a person adapt with the constant change of the environment.