What structured documentation and/or coded terminologies do you see within your practice setting (if none--where might they be applicable in your setting)?
A structured documentation is essential to avoid miscommunication, dropped orders, and protecting the public. Patient care begins when the physician has accepted them. At this time we (nurses) have to follow orders, identify the patient need, order ancillary care such as dietary, lab, social services, as well as medical needs. Implementation of these services collected in a structured method could decrease time for both nurse and patient with accurate documentation when implemented carefully and correctly. As our reading implied clarity is a strong reason for using a structured system. Handwriting is a precarious method of both writing and transcribing orders. I have witnessed many an error in medication time, medication administration, and the intended medication with hand written records. Writing nursing notes are laborious and often written with such brevity its difficult for quality assurance and billing to decipher or prove specific medical care was warranted or indicated per case causing a large loss in revenue. (Heba & Czar, 2009).
Using structured documentation also directs standard nursing language to establish correct communication and implementation of appropriate health care needs. (Heba T. C., 2009)
As a patient enters the system all of the health care team receive orders at this point a flow of client care would be expected. In my work setting we have an archaic and chaotic method of record keeping. Orders are overlooked or unnoticed creating communication and poor patient care provision. The lack in standard language also causes treatment to be botched including billing, quality assurance, and identifying measurable information for research or quality decision- making. This also includes the necessary appropriation of coding terminology to bring cohesiveness and clarity to medical documentation.
Coding terminologies are essential in reimbursement for services such as medical testing, care products, dietary, and other costs that accrue for hospital patient stay. Because we have lack of standards in both documentation, language, and knowledge of coding we have chaotic and minute measureable methods to track needs for payment.
According to Norma Lang, 1993 in coding classification clinical data slide 13 terminology is important to “represent concepts” as nurses we must be able to control what we do, receive financial reimbursement, aid in instructing and education along with obtaining information for research to improve patient care and create “public policy.” With each assessment, diagnosis, care planning, and evaluation nursing terminology places a huge part in the overall economics and administrative outcome of patient care. Nursing is not sole about taking vital signs, delivering medications, and offering comfort cares. Nurses provide evidence that will help in epidemiologic research, terminology, and naming health problems including care planning in order to code them for reimbursement. More importantly if we as APRN’s are expected to receive payment per services warranted this must be uniquely defined and appropriated for us to receive payment for services rendered. Our documentation and terminology is essential to our professional, the patient, ancillary practitioners, and protection of our license; as they (law) say “if it isn’t written, it wasn’t done.” Standardize terminology in both language and coding is essential.
2. Why is it useful to have standard terminologies for nursing documentation?
I believe nursing terminology must be standardized to prevent misunderstanding and miscommunication to avoid potential injurious errors particularly with charting and communication to other disciplines providing patient care. Nursing has been formulating their language “between health care venues” since the 1980’s (Murphy, 2010, p. 10). This standardization makes a great impact on obtaining best evidence in order to provide the best care and offer the best quality patient outcomes (Murphy, 2010, p. 10).
In order for nursing to be taken seriously as a profession it is also important to have a standardized terminology for billing purposes, identification of specific illness for coding, and it offers measurable information that increases allocation of resources (Murphy, 2010). Where I work documentation, standard language, and coding is all done per hand written paper. Not only due we lose revenue we have had serious mistakes in medication orders, diabetic treatments, and communication due to lack of appropriate structure and plain laziness of the nursing staff. I will be glad when we are forced to use structured documentation as it is intended.
References
Cheeseman, S. (2011, May). Module 2 Coding and classification of clinical data: Nursing
documentation, standards, coding systems/terminology. Slide 13. Online University of Utah.
Effken, J. (2003). Computers, Informatics, Nursing • Vol. 21, No. 6, 316–323. Lippincott
Williams & Wilkins, Inc.
Hebda, T., Czar, P. (2009). Health information systems. In Handbook of informatics for
nurses and health care professionals. (4th ed. ).
Hebda, T., Czar, P. (2009). The electronic health record. In Handbook of informatics for
nurses and health care professionals. (4th ed. ). NJ: Pearson-Hill Publishers
Murphy, J. (2010). Connecting for care: Nursing and health information exchange. Nursing Informatics, 24(3), 10-13.
