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DISCUSSION-3
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.
Please Provide References
Learning Resources
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. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning.
Chapter 6, “Overview of Nursing Informatics”
This chapter defines the foundations of nursing informatics (NI). The authors specify the disciplines that are integrated to form nursing informatics, along with major NI concepts.
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.
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.
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.html
The 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.
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.
Brown, B. (2011). ICD-10-CM: What is it, and why are we switching? Journal of Health Care Compliance, 13(3), 51–79.
Discussion:-4
Current Information and Communication Technologies
With so much attention focused on health care reform, it is important that nurses be given the opportunity to use high-quality technology tools. These tools can increase access to vital medical information, promote effective communication among health care professionals, and improve the patient experience. By actively seeking out and adopting these tools, nurses can greatly enhance the quality and safety of care that they provide.
This Discussion focuses on identifying quality technology tools that increase the ability of nurses to provide safe, effective care.
To prepare:
Review the various technology tools described in this week’s Learning Resources.
Identify a recently adopted information, education, or communication technology tool in your specialty area. Reflect on how it is used and how its use impacts the quality of care.
Consider how your identified technology tool might impact nursing practice if it were more widely used. What are some barriers preventing increased usage? How could wider implementation be facilitated?
Please Provide References
Learning Objectives
Students will:
Evaluate the effectiveness of a technology tool in your specialty area
Appraise the barriers and facilitators of implementing an information technology tool in your specialty area
Learning Resources
Required Readings
American Nurses Association. (2015). Nursing informatics: Scope & standards of practice (2nd ed.). Silver Springs, MD: Author.
“The Future of Nursing Informatics”
McGonigle, D., & Mastrian, K. G. (2015). Nursing informatics and the foundation of knowledge (3rd ed.). Burlington, MA: Jones and Bartlett Learning.
Chapter 12, “The Human-Technology Interface”
This chapter describes the human-technology interface and explores some of the problems that result from its usage. The author also reflects on methods for improving the interface.
Chapter 19, “Telenursing and Remote Access Telehealth”
This chapter explores the usage of telehealth in nursing practice. The authors examine the role of telehealth, along with potential issues that may arise in its usage.
Brewer, E. P. (2011). Successful techniques for using human patient simulation in nursing education. Journal of Nursing Scholarship, 43(3), 311–317.
This article identifies studies that have used human simulation as an effective instructional tool in nursing education. The article describes different strategies for incorporating human simulation into nursing education, and it also offers insight on improvements that could be made to current practices.
Guarascio-Howard, L. (2011). Examination of wireless technology to improve nurse communication, response time to bed alarms, and patient safety. Herd, 4(2), 109–120.
The author explains the results of a study on the outcomes of using wireless communication devices to improve patient safety by allowing nurses to communicate more quickly and easily with other nurses. The results indicate that this technology can increase the value of team nursing, improve response time, and increase patient safety, although there are some drawbacks and challenges associated with the devices.
Simpson, R. L. (2012). Technology enables value-based nursing care. Nursing Administration Quarterly, 36(1), 85–87.
This article describes how technology can be used to address problems in the U.S. health care system, such as lack of consistency and lack of effective treatment. The article explains the use of value-based care initiatives and outlines how nurses can use these initiatives to improve outcomes in treatment and research.
Vinson, M. H., McCallum, R., Thornlow, D. K., & Champagne, M. T. (2011). Design, implementation, and evaluation of population-specific telehealth nursing services. Nursing Economic$, 29(5), 265–272, 277.
Telehealth is defined as health services that integrate electronic information and telecommunications to improve health care access, outcomes, and costs. This article describes how a telehealth implementation project was designed, enacted, and evaluated, and it analyzes the results of that project.
Required Media
Laureate Education (Producer). (2012c). Health care technologies. Baltimore, MD: Author.
This video features Katie Skelton, Doris Fischer, Carina Perez, Shannon Mori, Carmen Ferrell, and Lynn Tamanaha as they discuss current technologies and innovations in health care. They also describe a specific bed management-system that has improved their hospitals’ efficiency.

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