Standardized Healthcare Terminology

It is our job as nurses, our piece to the healthcare puzzle, to provide the BEST possible care to every patient, every time. In doing so, we as nurses need to be diligent and compliant with our documentation, using the proper standardized healthcare terminology to establish a uniform representation of nursing care; an “unambiguous description of how nursing problems, interventions and outcomes are documented” (Hebda & Czar, 2013, p. 300). Our textbook (Hebda & Czar, 2013, p. 298) uses the definition of standardized terminology as; “structured and controlled languages that have been developed according to terminology development guidelines and have been approved by an authoritative body (HIMSS, 2006).” Using structured, standardized terminology
is a necessity to bedside nursing and the profession as it enables consistent use of terminology across all clinical settings and specialties. Adhering to these standards “will result in better communication to the interdisciplinary team, increase the visibility of nursing interventions, enhance data collection used to evaluate and analyze patient care outcomes, and support greater adherence to standards of care” (Hebda & Czar, 2013, p. 300). There are different terminology structures that expedite standardized medical terminology. Two examples that I will focus on being; the American Nurses Association (ANA) recognized nursing languages and nursing nomenclatures. Implementation and compliance with these systems will facilitate in positive patient outcomes, which in every case, is our number one goal. I will address an example of how standardized terminology was life changing for one patient of mine later in this paper.
American Nurses Association (ANA) Recognized Nursing Languages
The first facilitator that I’ll address in standardizing terminology will be that of the American Nurses Association (ANA) recognized nursing languages. Through the Committee for Nursing Practice Information Infrastructure (CNPII), the ANA has selected terminologies appropriate for use by nursing, meeting defined standards for approval to support nursing practice and reflect the nursing process (Hebda & Czar, 2013, p. 303). Data comprised in the nursing process includes assessment, diagnosis, outcome identification (goal), planning, implementation (interventions), and evaluation. Some examples of ANA approved terminologies include, but are not limited to, the following; North American Nursing Diagnosis Association (NANDA), Nursing Minimum Data Set (NMDS), Home Healthcare Classification (HHCC), OMAHA system, Nursing Interventions Classification/Nursing Outcomes Classification (NIC/NOC) and Patient Care Data Set (PCDS) (Hebda & Czar, 2013, p. 304). Most nurses who have graduated in the last 20 years, including myself, are familiar with the NANDA format, especially when it comes to writing patient care plans. By implementing these recognized terminologies when documenting in a patient’s electronic health record (EHR), during report, or any other mode of communication, nursing is successful in achieving a common language. Effective communication has the ability to be a patient’s first line of defense.
Nursing Nomenclatures
The second facilitator to standardizing terminology is through the use of nursing nomenclatures. Nomenclatures are the systematic approach to naming, with descriptions based off a pre-established set of rules. Systematized Nomenclature of Human and Veterinary Medicine Clinical Terms (SNOMED-CT) and The International Classification of Nursing Practice (ICNP) are examples of nursing nomenclatures valuable to our nursing practice (Coenen & Kim, 2010). According to Hebda & Czar (2013), “SNOMED-CT is a globally recognized controlled healthcare vocabulary that provides a common language for electronic health applications.” Hebda & Czar (2013) goes on to include that the ICNP is a unified nursing language system developed to “facilitate the development of and the cross-mapping among local terms and existing terminologies.” Together, their common goal is to produce and enhance a global clinical terminology standard by integrating the multiple current medical terminologies into one universal language. This is a very ambitious task that will take years to achieve, but the benefits will be insurmountable.
A Personal Experience A personal experience, when the critical importance of using standardized terminology presented itself, was during a subpoenaed court appearance.
The subpoena was in regards to a DCFS (Illinois Department of Children & Family Services) case of an infant who was treated at our facility for a skull fracture and bilateral retinal hemorrhages. Both mother and boyfriend (not the infant’s father) stated that the infant rolled off the couch and they called 911 when they noticed the infant wasn’t breathing and blue. As I was caring for this infant’s roommate, behind a closed curtain, I overheard the mother and boyfriend arguing about the incident. Unbeknownst to the couple, I overheard details of how the mother was so upset with her boyfriend for throwing her baby up against the wall. The boyfriend proceeded to apologize to his girlfriend for losing his temper and throwing her baby. They went on with their conversation while I listened and continued to care for the roommate on the other side of the curtain. After leaving the room, I directly logged on to the patient’s EHR and documented everything I had heard. I knew the couple’s first and last names and made sure to include every detail and quoted statements made by both individuals. So many aspects in nursing are intertwined, data integrity played a very large role at this moment as well. It’s easy to form opinions after observations such as this. Speaking from experience, when initial data is entered into an EHR, it’s
easy for nursing to inadvertently follow suit with the same documentation, therefore, making date integrity and accuracy imperative. I then called DCFS and the attending physician to inform them of my assessment and included that information in my note as well. As this infant was at our facility for some time, it was vital to adhere to standardized nursing terminology when documenting in his EHR. We all knew our charting would be presented before a court of law and be analyzed and scrutinized by a criminal defense lawyer. The outcome of this baby’s future depended on the accuracy through standardization of our charting. In this specific case, the stars all aligned as several of my co-workers also received subpoenas to appear in court. Together, with our standardized documentation and verbalized descriptions, this beautiful baby was removed from his current unsafe environment and placed into one of love and security. Unfortunately, every case doesn’t always have similar positive outcomes as this. Due to holes in communication and conflicting descriptions in nursing documentation, a patient’s EHR has the potential to be an incompetent source when trying to prove abuse in a court of law. When nursing fails to be an advocate to a patient population without a voice, this is of the utmost tragedy.
Conclusion
Again, standardized terminology is defined as, “structured and controlled languages that have been developed according to terminology development guidelines and have been approved by an authoritative body” (HIMSS, 2006).
Classifications and terminologies are what form the information content in a patient’s electronic health record or personal health record. Making sure the information is standardized comes with multiple benefits that seem limitless. An article by Rutherford includes the benefits in using standardized terminology; it promotes “better communication among nurses and other health care providers, increases visibility of nursing interventions, improves patient care, enhances data collection to evaluate nursing care outcomes, increases adherence to standards of care, and facilitates assessment of nursing competency.” (Rutherford, 2008). When healthcare terminology is universally understood, researching patient care outcomes nationally and worldwide thru evidence based practice, is made possible. The goal to produce and enhance a global clinical terminology standard, by integrating the multiple current medical terminologies into one universal language, will be a difficult process to achieve for years to come. Furthermore, we know patients have better outcomes when communication is functioning at its highest level, therefore, the work continues. My job as a nurse will be to adhere and comply with standardized terminologies no matter where my nursing career may
take me. As you have stated before Professor Phillips, “Work smarter not harder.”