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
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
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