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The importance of standardized nursing language
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Using standardized nursing languages in nursing documentation is just as important as providing care, because if it was not documented properly it was not done in the nursing world. (Rutherford, 2008), “Standardized language provides nurses with a common means of communication. Both convey the idea that nurses need to agree upon a common terminology to describe assessments, interventions, and outcomes related to the documentation of nursing care” (P.1). From the beginning of nursing school in the ADN program, nursing terminology was taught and the importance of it was stressed to every novice in class. Nursing language enables us to communicate effectively in the nursing community and to share important data in our field. Without a standardized …show more content…
(McGonigle & Mastrian, 2015 ), “The creation of nursing taxonomies and nomenclatures has occurred over the past years. The ANA has formalized the recognition of these languages and vocabularies through a review process of the Committee on Nursing Practice Information Infrastructure” (P.101). Nursing standardize language is used widely in the electronic charting system that is now commonly used in nursing. Nurses are now able to record data electronically using the standardized nursing language. (Park & Lee, 2015), “The pressure to constrain costs while continuing to provide a high quality of care has increased the need for reliable healthcare data. As a result, electronic health records (EHRs) with standard terminologies have become a requirement for all healthcare providers and organizations nationally and internationally. As with other health disciplines, nurses have realized that standardized languages in nursing information systems are required to systematically collect nursing data for evaluating quality assurance and costing nursing service” (P.35) . The article stressed the significance of the usage of standardize language in electronic charting. In brief, standardize nursing language is beneficial to health care as a whole. It aids us in data collection and in competently performing our duties as
The adoption of clinical information systems is one way that healthcare organizations are making an effort to improve patient safety, provide a means to exemplify regulatory compliance, and facilitate exchange of patient information between care providers (Kirkley & Stein, 2004; Nadzam, 2009). To achieve this goal, Barnes-Jewish Hospital (BJH) recently implemented a new CPOE/clinical documentation system. One of the objectives of the new system was to give bedside clinicians a standardized electronic tool, known as the Clinical Summary, for bedside shift hand-off reporting. Soon after go-live, it was identified that the standard nursing Clinical Summary did not meet specialized the reporting needs of the nurses on the Women and Infants divisions. Consequently, an application enhancement request was submitted. The goal of this project is to synthesize the knowledge gained throughout this Masters Degree program to initiate, plan, and execute changes to the current clinical documentation system to provide a standardized Clinical Summary review screen to meet the specialized hand-off reporting needs of the nurses on the Women and Infants divisions at BJH. This paper includes project objectives, a supporting evidence-based literature review, project methodology, formative and summative evaluation criteria, and a graphical timeline with a narrative description for the Women and Infants Clinical Summary project.
Rutherford, M. "Standardized Nursing Language: What Does It Mean for Nursing Practice?" OJIN: The Online Journal of Issues in Nursing 13.No. 1 (Jan. 31, 2008). 4 October 2015. .
... middle of paper ... ... Works Cited 1. Cooper, Paul, RN, MSN, Director of Nursing Informatics.
When I am older I would love to be a Nurse Practitioner, I enjoy helping people when they are sick and taking care of them. Another reason I want to be a Nurse Practitioner is because my sister is also a Nurse Practitioner.
Licensed practical nurses (LPN 's) fill an important role in modern health care practices. Their primary job duty is to provide routine care, observe patients’ health, assist doctors and registered nurses, and communicate instructions to patients regarding medication, home-based care, and preventative lifestyle changes (Hill). A Licensed Practical Nurse has various of roles that they have to manage on a day to day basis, such as being an advocate for their patients, an educator, being a counselor, a consultant, researcher, collaborator, and even a manager depending on what kind of work exactly that you do and where. It is the nursing process and critical thinking that separate the LPN from the unlicensed assistive personnel. Judgments are based
Standards are important aspects of nursing that a nurse must learn and implement every day for the rest of their nursing career. These standards provide for a nurse’s competence in the quality of care they deliver to the public. Standards offer a necessary guidance to nurses everywhere in an effort to ensure that people are treated correctly and ethically. Patients expect nurses to have a general knowledge of the medical realm and to know exactly what it is they –as nurses- are responsible for. Nurses need to have a sense of professionalism that enable the patient to feel safe and secure, knowing that a competent person is caring for him. A lack of professionalism does the opposite, making it impossible for a patient to trust or respect the nurse caring for him. Standards of nursing, if utilized correctly, give the nurse that sense of professionalism the patient is expecting. It insures for the safety of the patient and allows the nurse to provide quality health care that is expected of a medical professional.
The authors consist of nurses, specifically: a Chief Nursing Officer, a Nursing Informatics Officer, and a Dean/Professor of Nursing at Belmont University. The article described how vital nursing documentation is to achieve optimal patient care, including improving patient outcomes & collaborating with other healthcare providers. Using Henderson’s 14 fundamental needs as a framework for their research, the authors proved a definition of basic nursing care and incorporated it into an electronic health record. The authors utilized a team of 16 direct care nurses who were knowledgeable with documenting ele...
Over the past decade, technological advances have paved the way for nurses to provide, quality, safe, standardized and individualized patient care (Saba & McCormick, 2015). The use of the Electronic Health Records (EHR) to manage patient data is quickly becoming widespread in the healthcare industry. The emerging use of the Electronic Health Record, is transforming how nurses care for patients. By creating and implementing an electronic, comprehensive, standardized method of recording patient data, nurses can facilitate and coordinate patient care with members of the multidisciplinary healthcare team. The use of the Electronic Health Record will promote positive
“Life is a balanced system of learning, adjusting, and evolving. Whether pleasure or pain; every situation in your life serves a purpose. It is up to us to recognize what that purpose could be.” - Dr. Steve Maraboli
Nurses today need to have excellent communication skills. Receiving information from patients is the most important aspect of nursing. If nurses are unable to communicate with their patient then they would not be able to have a relationship with them. Communication is where two or more people interact with each other, by using sounds and words, this is verbal communication. Some individuals have different behaviors where they try to express themselves to others without using spoken words, this is non verbal communication. Once nurses have the proper communication tools, techniques and evidence based practice, when communicating with their patient, they would get the necessary information needed from the patient to properly diagnosis them.
According to the American Nurses Association, nursing is defined as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations” (American Nurses Association, 2016). Nurses have many jobs and responsibilities and wear many different hats. Nurses can perform at many different levels depending on their scope of practice which is defined by the board of nursing in one’s state of residence. It is important as nurses to understand and follow
What is the central component of advanced practice nurses (APNs) direct clinical practice and patient/families?
Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as “anything which has been entered into a patient’s electronic health record or written in a patient record” (Perry, 2014, p. 47). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014, p. 47). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that, “As regulated health care professionals, nurses are
3). The RWJF recommends a multidisciplinary and unified approach to data collection. To meet this goal, The Workforce Commission and the Health Care Resources and Services Administrations are expected to develop a standardized minimum set data that will be include nursing, dentistry, medicine, and pharmacy disciplines across states. It is imperative that nursing expertise is sought and incorporated on the Workforce Commission membership (IOM, Report Recommendations, 2010, p. 6). A year ago, my hospital transitioned from Affinity (hospital based) to Orchid (county-wide based). I became familiar with Affinity during medsurg clinical rotation. I remember one of the downsides of the system was that nurses were only able to see all documentation recorded at that specific hospital. Since we started Orchid, we are able to access patient’s information from all county hospital at once. I value the importance of having a standardized data system that enables better communication among all disciplines and more realistic staffing expectations.
Data and information are integrated into each step of the nursing process: assessment, diagnosis, planning, implementation, and evaluation. ("Nursing Excellence." Nursing Informatics 101. Web. 19 Nov. 2014.) Following this process, nursing informatics personnel can organize and set each file and record accordingly based on the care process. Since health care providers communicate primarily through the notes they write in a patient’s chart, nurse informaticists seek to continually improve the speed, timeliness and accuracy of patient charting. Working with the accurate information is key to nurses in all fields of the spectrum. It is beneficial to the health care providers that information is precise and up-to-date so the care will be more than sufficient. When health workers have access to more up-to-date, complete patient notes, they can make better decisions about a patient’s care and use the appropriate resources to better help the quality of the patient’s care doctors can