In: Nursing
You've been hired as an informatician at a state health department. The health department is developing systems to receive laboratory and clinical case reports from clinical settings, such as hospitals and doctors’ offices. Your state has an immunization Registry in operation for several years and has been successful in getting cooperation from healthcare settings to send out to the system.
Question: Describe your interest in and experience with standardized terminologies. List at least three positive and three negative experiences with standardized terminologies. What can be done to transform the negative experiences into positive ones?
A standardized terminology is simply a common language, nomenclature, or taxonomy designed to be shared among users.
In health care settings, use of standardized terminologies is essential to clearly and accurately document client documentation, assessment, care and outcomes.
Benefits
The one example of standardized terminology is omaha system, one of the best nomenclature to be developed is a research based and provides interoperability and communication across the community health, health clinicians, administers, educators and researchers.it include 3 components
1. The problem classification scheme
2.The intervention scheme
3.The problem rating scale for outcomes.
The standardized terminologies having postives and negatives.
Positives are:
- standardized terminologies is essential to clearly and accurately document the client assessment, care and outcomes.
-standardized terminologies provide a consistent basis for communicating the unique contributions of nursing to direct patient care and to research.
-better communication among nurses and other health workers and increased visibility of nursing interventions and resultant patient outcomes, improved patient care, greater adherences to standards of care.
Negatives:
-lack of interoperability is one disadvantage of standardized terminologies. A necessary element in healthcare system is interoperability.
-standardization is critical for sharable data needed to deliver care and coduct research effectively.however lack of harmonization across the standards inhibits goal of shared data.eg: multiple nursing assessment scales, pain scale includes numerical rating scale, visual analogue scale and categorical scale. The lack of standardized assessment tools make it difficult.
-another disadvantage is there is no centralized system all over the country, several facilities use different systems.there is the lack of communication and sharing of data across the system.