Standardized Nursing Language
A standardized nursing language for documentation of nursing care is important to the nursing profession and to the care providing nurse (Rutherford, 2008). Nursing has always faced by two challenges including, to distinguish nursing contributions in patient care from medicine and to incorporate nursing care into the healthcare to improve the patient’s care. As the development of Electronic Health Records (EHR) and the establishment of Nationwide Health Information, these challenges become more significant. It became essential to identify nursing contributions in patient care and to incorporate elements of nursing care in to the EHR. This quandary was resolved by using standardized nursing terminologies to reflect the uniqueness of nursing
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This way nurses from nationally and internationally can share a common terminology to identify the specific problem or intervention implied and the outcome observed. The American Nurses Association has recognized 12 standardized nursing terminologies (Rutherford, 2008). As my chosen specialty is nurse practitioner, I would like to adopt SNOMED CT which provide comprehensive medical terminologies. SNOMED CT supports the development of high quality content in health records. It provides standardized clinical phrases, which can be used by the clinicians easily and permits automatic interpretation. As I am not aware of many of these terms and using this terminology allows me to record my clinical information at appropriate levels of detail using relevant clinical concepts. SNOMED CT provide guideline and decision support system to check the record and provide real time advice through clinical alerts. It allows to record the clinical information accurately during a consultation. SNOMED allows the easy sharing of patient care information among care providers. It removes the language barrier as SNOMED enables multilingual use. SNOMED enables early identification of emerging health issues, monitoring of population health and responses to changing clinical practices. Therefore SNOMED CT has a comprehensive clinical coverage and comprises a depth of detail appropriate to a range of health care disciplines and clinical
This way nurses from nationally and internationally can share a common terminology to identify the specific problem or intervention implied and the outcome observed. The American Nurses Association has recognized 12 standardized nursing terminologies (Rutherford, 2008). As my chosen specialty is nurse practitioner, I would like to adopt SNOMED CT which provide comprehensive medical terminologies. SNOMED CT supports the development of high quality content in health records. It provides standardized clinical phrases, which can be used by the clinicians easily and permits automatic interpretation. As I am not aware of many of these terms and using this terminology allows me to record my clinical information at appropriate levels of detail using relevant clinical concepts. SNOMED CT provide guideline and decision support system to check the record and provide real time advice through clinical alerts. It allows to record the clinical information accurately during a consultation. SNOMED allows the easy sharing of patient care information among care providers. It removes the language barrier as SNOMED enables multilingual use. SNOMED enables early identification of emerging health issues, monitoring of population health and responses to changing clinical practices. Therefore SNOMED CT has a comprehensive clinical coverage and comprises a depth of detail appropriate to a range of health care disciplines and clinical