Standardized Nursing Language System By NANDA, Benefits Of Standardized Language And Experience With Healthcare Information System

Essentials of Managed Health Care

Standardized nursing language system by NANDA

Describe about standardized nursing language system by NANDA, Benefits of standardized language and experience with healthcare information system.

Healthcare information system s is one kind of system that can manage, capture, store and transmit health related information of patients or organizational process in the healthcare settings. Healthcare information system helps in decision-making through all the health system building blocks. It has significant role in health system policy development and implementation along with health research, governance, regulation, health education, training and financial purposes related to health care services (Padhy, Patra & Satapathy, 2012). The healthcare information system usually serves for four major functions; these are health related data generation, compilation, analysis and synthesis as well as communication and use. The healthcare information system is associated with monitoring and evaluation by providing alerts and early warning capability, supporting and simulating health research, health facility management and communication needs (Oliveira Lopes et al., 2012). The healthcare information system also helps the service users to access their health related information and to understand implication of medical services. The main purpose of this assignment is to explore the healthcare information system usage and their use in its impact on health care delivery.

NANDA is an organization of standardized nursing terminology. The organization was established in 1982. The main objective of this organizational system is to research, develop, disseminate and process the taxonomy and nomenclature of nursing diagnosis.  The organization established a nursing nomenclature and classification system, which is able to develop a language, describing the nurse’s clinical judgment about a health condition (Gagnon et al., 2012). The system includes the development of a universal nursing language system through which nurses can undertake clinical judgment for nursing diagnosis, intervention and outcomes. This system helps in coordinating care within national and international settings. This classification system helps nurses to understand the importance of nursing diagnosis. The nursing diagnosis helps in the correct clinical judgment by the nurses and reduces misinterpretation (Wachter, 2012). Nursing diagnosis refer to the set of processes for gaining the depth of information necessary for making an accurate nursing intervention plan. The definitions and classification in the system provides a standardized classification system for clinical judgment by the nurses.

Standardization of nursing language is important for documenting nursing care services correctly. According to Barbarito et al., (2012) since the primitive period of nursing, there is a wide range of uni-specific terminology described within the nursing field. Thus, using common languages in nursing practices, which would be readily understood by all the nurses for describing nursing care.

Benefits of standardized language

Based on the standardized language, a standard nursing nomenclature and classification has been established by NANDA. In the current structure or nursing diagnosis classes based on standardized languages, the classification is known as Taxonomy II, having three levels. Based on standardized languages, 13 domains have been classified in the system along with 47 classes (Herdman, 2011). The domains included health promotion, nutrition, activity/rest, elimination/exchange, self-perception, perception/cognition, role relationship, life principles, sexuality, coping/stress tolerance, comfort and growth/development, safety/protection (Juve Udina et al,. 2012).

Benefits of standardized language

• Using standardized language system helps to improve communication among nurses and other health care providers
• It helps to increase visibility of nursing interventions
• The language system has significant contribution in improved patient care through enhanced data collection and evaluation of outcomes (Cardenas-Valladolid et a., 2012)
• Standardized languages enhances the adherence to of nursing practices to the standards of care
• It facilitates the assessment of nursing competency

Electronic health record or EHR systematic software that collects and store patient or population’s health information in a digital format. It is one of best-known example of healthcare information system. The system stores patient’s health information in such a way that information can be shared in different heath care setting; through enterprise-wide information systems. The system records include patient’s medical history, demographics, medication, allergies, laboratory test results, vital signs and symptoms indicting particular disease, radiology images, immunization status, required tests, personal statistics including age, weight, height, details of doctor and other medical professionals assigned to the patient, billing information, hospitalization information and other personal information that might be required for health care planning of the patient (Kongstvedt, 2012). There are more than 100 electronic health record systems used in various field within health care framework.

Goals and objectives

The system developer established this universal healthcare information system with some objectives. These include:

• Improvement of care quality, efficiency and safety
• Reduction of health disparities
• Quality and safety measurement
• Improvement of care coordination
• Engagement of patient and family in care plan
• Improvement of population and public health
• Privacy and protection of data from misuse

Technical features

• Track care and outcomes records, for example prescriptions and blood pressure reports
• Digital formatting helps to use information and share over secure networks
• Send and receive reports, orders and results
• Trigger warnings and reminders
• Reduce the processing time of billing and enhance its accuracy
• Exchange of electronic information between organizations through technical and social framework
• In some systems, there is an option for automatic monitoring of clinical events. One such system is Louisiana public health information exchange, that links state wide public health with electronic medical records.

As the electronic health records are created to share information with other health care facility providers including laboratory, medical imaging facilities, pharmacies, emergency facilities, specialists, school and workplaces; thus, it contains information of all clinicians related to patient care (Hsiao & Hing, 2012).

Implementation

The implementation of electronic health record system involves six simple steps.

1. Assessment of practice readiness
2. Planning the approach
3. Selection or upgradation to a certified EHR
4. Conducting training and implementation of HER system
5. Achievement of meaningful use
6. Continuation of quality improvement

Advantages

• The system provides accurate and complete patient information
• Coordinated and efficient care is provided by enabling quick access to patient records
• Sharing secure electronic records with patient and other clinicians improves patient’s outcomes by systematic approach
• It helps in promoting legible, complete documentation and accurate coding
• The system helps to enhance privacy and security of patient data
• The system reduce entire health care cost by reducing paperwork or duplication of testing, improving overall health and safety
• Use of this system helps to improve the quality of care delivery through improved care coordination within the team (Jamoom et al., 2012)
• It helps to meet business goals through the improvement of the health care service quality provided by the organization

Healthcare information system has a significant contribution in health care system. The health care system has a positive impact upon the patient’s health outcomes along with the quality of health care delivery. Being a nurse, I have experienced benefits while experiencing healthcare information system in my workplace. I have noticed that I used to make more mistakes before using electronic health records for patients. However, as soon as I have started to maintain patient’s tracks through electronic health records in spite of using manual tracks, it helped me to reduce the rate of medication errors (Charles, Gabriel & Furukawa, 2013). Medication error or any kind of misconduct can be offensive in the health care settings, as it can be life threatening for a patient. I have always tried to avoid any kind of errors in my work. However, due to huge pressure during my work, sometimes I used to misinterpret some services. However, e-health records helped me to manage patient-specific medications and other care services. On the other hand, it helped me to improve my time management skills in health care settings.

E-health records

 In addition, as electronic health records helped me in managing the health care services in a systematic way, my productivity also improved significantly. Now, I can contribute more positively to the patient’s faster recovery. Efficient time management and enhanced productivity also have a positive impact upon my personal life through significant job satisfaction and elimination of nursing burnout. In addition, the electronic health records also helped in eliminating misunderstanding with other nurses during the change of shift time. I used to keep patient’s medical track manually and used to hand over those track to the nurse in the next shift, any kinds of misinterpretation or error promote wrong health care service delivery by the nurse in next shift. I have successfully eliminated these kinds of misconducts, after using electronic health records. One negative impact of the healthcare information system is that, it is making us more technical and reducing our ability to hard work.

Conclusion

In conclusion, it can be said that health information system has a significant impact on the improvement of health care service quality delivered to the service users. There are a number of applications of healthcare information system in health care settings. Two commonly used healthcare information systems have been demonstrated here along with the uses, benefits and unique features of these systems.  In addition, the personal experience with the healthcare information system has also been demonstrated, as a registered nurse.

Reference List

Barbarito, F., Pinciroli, F., Mason, J., Marceglia, S., Mazzola, L., & Bonacina, S. (2012). Implementing standards for the interoperability among healthcare providers in the public regionalized Healthcare Information System of the Lombardy Region. Journal of biomedical informatics, 45(4), 736-745.

Cardenas-Valladolid, J., Salinero-Fort, M. A., Gomez-Campelo, P., de Burgos-Lunar, C., Abanades-Herranz, J. C., Arnal-Selfa, R., & Lopez-Andres, A. (2012). Effectiveness of standardized Nursing Care Plans in health outcomes in patients with type 2 Diabetes Mellitus: a two-year prospective follow-up study. PloS one, 7(8), e43870.

Charles, D., Gabriel, M., & Furukawa, M. F. (2013). Adoption of electronic health record systems among US non-federal acute care hospitals: 2008-2012. ONC data brief, 9, 1-9.

de Oliveira Lopes, M. V., da Silva, V. M., & de Araujo, T. L. (2012). Methods for establishing the accuracy of clinical indicators in predicting nursing diagnoses. International Journal of Nursing Knowledge, 23(3), 134-139.

Gagnon, M. P., Desmartis, M., Labrecque, M., Car, J., Pagliari, C., Pluye, P., … & Légaré, F. (2012). Systematic review of factors influencing the adoption of information and communication technologies by healthcare professionals. Journal of medical systems, 36(1), 241-277.

Herdman, T. H. (Ed.). (2011). Nursing Diagnoses 2012-14: Definitions and Classification. John Wiley & Sons.

Hsiao, C. J., & Hing, E. (2012). Use and Characteristics of Electronic Health Record Systems Among Office-Based Physician Practices, United States, 2001-2012 (pp. 1-8). US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.

Jamoom, E., Beatty, P., Bercovitz, A., Woodwell, D., Palso, K., & Rechtsteiner, E. (2012). Physician adoption of electronic health record systems: United States, 2011. NCHS data brief, 98(July).

Juvé Udina, M. E., Gonzalez Samartino, M., & Matud Calvo, C. (2012). Mapping the diagnosis axis of an interface terminology to the NANDA International Taxonomy. ISRN nursing, 2012.

Kongstvedt, P. R. (2012). Essentials of managed health care. Jones & Bartlett Publishers.

Padhy, R. P., Patra, M. R., & Satapathy, S. C. (2012). Design and implementation of a cloud based rural healthcare information system model.Univers J Appl Comput Sci Technol, 2(1), 149-157.

Wachter, R. M. (2012). Understanding patient safety. New York: McGraw Hill Medical.