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- QUESTION
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.
This week, you assess the purpose of standardized terminology in informatics. In addition, you are introduced to the continuum of data, information, knowledge, and wisdom, and you consider the key elements of each stage.
Learning Objectives
Students will:
Assess the importance of standardized terminologies used to document patient care
Apply the data, information, knowledge, and wisdom continuumLearning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
American Nurses Association. (2015). Nursing informatics: Scope & standards of practice (2nd ed.). Silver Springs, MD: Author.
“Metastructures, Concepts, and Tools of Nursing Informatics”This chapter explores the connections between data, information, knowledge, and wisdom and how they work together in nursing informatics. It also covers the influence that concepts and tools have on the field of nursing.
McGonigle, D., & Mastrian, K. G. (2018). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones and Bartlett Learning.
Chapter 6, “History and Evaluation of Nursing Informatics”
Brokel, J. (2010). Moving forward with NANDA-I nursing diagnoses with Health Information Technology for Economic and Clinical Health (HITECH) Act Legislation: News updates. International Journal of Nursing Terminologies & Classifications, 21(4), 182–185.
Retrieved from the Walden Library databases.In this news brief, the author describes the initiatives that NANDA-I will implement to remain abreast of the HITECH legislation of 2009. The author explains two recommendations for the federal government’s role in managing vocabularies, value sets, and code sets throughout the health care system.
Matney, S., Brewster, P. J., Sward, K. A., Cloyes, K. G., & Staggers, N. (2011). Philosophical approaches to the nursing informatics data-information-knowledge-wisdom framework. Advances in Nursing Science, 34(1), 6–18.
Retrieved from the Walden Library databases.This article proposes a philosophical foundation for nursing informatics in which data, information, and knowledge can be synthesized by computer systems to support wisdom development. The authors describe how wisdom can add value to nursing informatics and to the nursing profession as a whole.
Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? OJIN: The Online Journal of Issues in Nursing, 13(1). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursingLanguage.htmlThe author of this article provides justification for the use of a standardized nursing language, which will be necessary for incorporating electronic documentation into the health care field. The author defines standardized language in nursing, describes how such a language can be applied in a practice setting, and discusses the benefits of using a standardized language.
Westra, B. L., Subramanian, A., Hart, C. M., Matney, S. A., Wilson, P. S., Huff, S. M., … Delaney, C. W. (2010). Achieving “meaningful use” of electronic health records through the integration of the Nursing Management Minimum Data Set. The Journal of Nursing Administration, 40(7–8), 336–343.
Retrieved from the Walden Library databases.This article explains the nursing management minimum data set (NMMDS), which is a research-based minimum set of standard data for nursing management and administration. The article describes how the NMMDS can be used to minimize the burden on health care administrators and increase the value of electronic health records within the health care system.
Required Media
Laureate Education (Producer). (2012a). Data, information, knowledge, and wisdom continuum. Baltimore, MD: Author.
McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (2nd ed.). Burlington, MA: Jones & Bartlett Learning. (p. 98, Chapter 6, Figure 6)The continuum of data, information, knowledge, and wisdom is used in the health care field to describe discrete levels of understanding related to patient care and decision making. This video provides an overview of the continuum from data to wisdom.
Optional Resources
Truran, D., Saad, P., Zhang, M., & Innes, K. (2010). SNOMED CT and its place in health information management practice. Health Information Management Journal, 39(2), 37–39.
Retrieved from the Walden Library databases.
Brown, B. (2011). ICD-10-CM: What is it, and why are we switching? Journal of Health Care Compliance, 13(3), 51–79.
Retrieved from the Walden Library databases.
Discussion: Standardized Coding Systems
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.
To prepare
Review the information in Nursing Informatics: Scope and Standards of Practice. Determine which set of terminologies are appropriate for your specialty or area of expertise.
Reflect on the importance of continuity in terminology and coding systems.
In the article, “Standardized Nursing Language: What Does It Mean for Nursing Practice?” the author recounts a visit to a local hospital to view its implementation of a new coding system. One of the nurses commented to her, “We document our care using standardized nursing languages but we don’t fully understand why we do” (Rutherford, 2008, para. 1). Consider how you would inform this nurse (and others like her) of the importance of standardized nursing terminologies.
Reflect on the value of using a standard language in nursing practice. Consider if standardization can be limited to a specialty area or if one standard language is needed across all nursing practice. Then, identify examples of standardization in your own specialty or area of expertise. Conduct additional research using the Walden Library that supports your thoughts on standardization of nursing terminology.
| Subject | Nursing | Pages | 5 | Style | APA |
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Answer
Description of Pain
Pain is something which everybody at one point feels in his or her life. It is important to note that an individual’s pain is absolutely distinct from the next person’s. Pain is usually described or defined in terms of damage. It refers to an unpleasant emotional and sensory experience related to potential or actual tissue damage (Truran, Saad, Zhang, & Innes, 2010). Some of the words I use to describe pain include achy, itchy, agonizing, and griping (Hoy & Frith, 2017). An achy pain refers to a continuous pain which is not very strong and results when part of a body becomes sore. Agonizing pain, on the other hand, is very painful and is felt when one knocks part of a body on a hard object while an itchy pain is an unpleasant feeling on the skin that makes one want to scratch the body part.
My colleagues, on the contrary, use different words such as severe, stiff, and stinging to describe pain. A severe pain results from a serious illness or injury. It is always very painful and makes the victims uncomfortable. A stiff pain is felt when one feels an unpleasant experience in the muscles since they cannot move easily. Contrariwise, the colleagues describe a stinging pain as one which hits very hard. Patients usually use different words or adjectives when discussing their level of pain (Venes, 2009). The different descriptions give health care providers a hard time to find or assess the cause of the pain and treat it. Some patients use adjectives which are never known to the health care providers, therefore, giving care providers problems in determining the cause and selecting proper management option since different pains require different management options.
References
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Truran, D., Saad, P., Zhang, M., & Innes, K. (2010). SNOMED CT and its place in health information management practice. Health Information Management Journal, 39(2), 37-39. Venes, D. (2009). Taber's cyclopedic medical dictionary. FA Davis. Hoy, H., & Frith, K. H. (Eds.). (2017). Applied clinical informatics for nurses. Jones & Bartlett Learning.
Appendix
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