Meaningful Use In Nursing Care

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As electronic health records (EHR) have been introduced and with the developments in health information technology, standardized terminologies have been developed. Standardized terminology is the organized and managed terms developed according to guidelines and accepted by an accredited body (Hebda, 2013). These terms, often referred to as controlled terminologies, ensure accurate and valid data collection. It allows data collected to be shared with other departments and facilities. Using the interoperable data collected can reduce omission errors and eliminate duplicate testing, therefore reducing healthcare costs. Standardized nursing terminologies captures nursing’s contribution and reflects the unique nursing care elements within the EHR. …show more content…

Standardized terminology used in the EHR allows organizations to comply with Meaningful Use. Reimbursement is based on the components of Meaningful Use. As Meaningful Use comes together with ICD-10 and performance based reimbursement, it is necessary for a common medical vocabulary. SNOMED CT has been in existence since 1965 and is accepted internationally. “The system enables computers to understand medical language and act on it through a large set of concepts and descriptions representative of many standard industry terminologies” (Levy, 2013). In a survey published in 2011, 1268 nurses were asked how familiar they were with standard terminology. Of that number of completed surveys, 61.6 % of the nurses reported they have no knowledge of or experience with SNOMED. I think they have probably used it more often than they realize with the use of electronic medical …show more content…

In turn, this enhances patient care and outcomes. This documentation will provide necessary patient data and will be accessible through the EHR. Nursing interventions performed and documented give valuable information to the patient’s health and outcomes since the health maintenance, follow -up and compliance will be trackable. When a patient established in our clinic is admitted to the hospital, the hospital is not able to access our EHR so it isn’t possible for them to see the patient’s current medications or diagnoses. However, the hospital is in our health system and our office is capable of logging in to the hospital’s system and seeing the patient’s inpatient records. This is helpful when the patient comes in for a follow up after hospitalization as the provider can address the reasons for admission as well as any medication changes. Unfortunately, and medication changes or new diagnoses with ICD-10 codes must be input manually by our staff. The hospital has none of this information from prior to the patient’s hospital stay since they aren’t able to access our EHR so they must call and request any records that may be pertinent in treating the patient. When a patient sees another provider like ENT, psychiatry, orthopedist, neurosurgeon, etc., our clinic does not have access to the records and therefore are unable to incorporate any medication changes or health

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