Knowledge and Information Management
What words do you use to describe pain? What words do your colleagues use to describe pain? Does every patient use the same adjectives when discussing his or her level of pain? Consider the problems these differences can create when attempting to assess a patient’s health concerns.
Health information technology has greatly increased the opportunity for the exchange of meaningful data and information across health care systems; however, in order for that to successfully occur, care must be taken to ensure that patient data is entered in a manner that allows for that information to retain its meaning across different systems. To be able to use health information technology to its greatest advantage, nurses need to gain an understanding of how data and information can be standardized and organized.
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.