Name: LOVELYNE DALEY
Introduction (min 100 words
This is a critical review of the article entitled “Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care”. In this article, Lundberg, C.B. et al. review the different standardized terminology in electronic health records (EHR) used by nurses to share medical information to the rest of the care team. It aims at showing that due to the importance of nursing in patient care, there is a great need for a means to represent information in a way that all the members of the multidisciplinary medical team can accurately understand. This standardization varies from organization to organization as the terminologies change with respect to their specialized needs.
This article reviews the advantages of integrating into an EHR, the various standardized nursing terminologies currently in use and acknowledged by the American Nursing Association (ANA) which are CNC, NANDA, NIC, NOC, Omaha System, PNDS and SNOMED CT. The authors make a strong and valid point in their description of these terminologies, their integration into EHRs and how they are positively impacting nursing care, research, education and clinical practice as a whole.
Summary (min 200 words)
Using standardized terminologies in nursing practice has a wide array of advantages to the patients, the organization involved, the nursing profession and even the country using the standards. These terminologies aid the healthcare organization (both the care team and administrators) in deciding which nursing terminology or a combination of several that suits their needs. With these terminologies:
Patients benefit from improved communication between members of the care team
Or...
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... to ensure that it meets their individual organizational needs, be it acute care, hospice care, general practice or even subspecialty care.
Works Cited
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This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the adaptation, utilization, and functionality of an EHR. The impact the EHR could have on a general population is invaluable; therefore, it needs special attention from a trained professional.
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Electronic medical records not only effect health care professionals, but the patients of those health care providers as well. However, nurses spend the most time directly using electronic medical records to access patient date and chart. Nurses now learn to chart, record data, and interact with other health care providers electronically. Many assume that electronic means efficient, and the stories of many nurses both agree, and disagree. Myra Davis-Alston, a nurse from Las Vegas, NV, says that she “[likes] the immediate access to patient progress notes from all care providers, and the ability to review cumulative lab values and radiology reports” (Eisenberg, 2010, p. 9). This form of record keeping provides health care professionals with convenient access to patient notes, vital signs, and test results from multiple providers comprised into one central location. They also have the ability to make patients more involved in their own care (Ross, 2009). With the advancement in efficiency, also comes the reduction of costs by not printing countless paper records, and in turn, lowers health care
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Each of the classifications involves distinctive data components. The environment category comprises of six data features including unit/service unique identifier, type of nursing delivery unit/service, patient/client population, volume of nursing structure and outcomes, patient/client accessibility, and accreditation/certification/licensure. Nurse resources category consists of staffing, satisfaction, nurse demographics per unit or service, clinical mental work, environmental conditions, and electronic health records (EHR) implementation stages. The nurse resources category is at the management level; nurse administrators categorize unities, and variations, of employees and conditions that are associated with the delivery of care. This allows measurements and evaluation of the care and resources within and across settings (Myun Sook et al.,
Taylor, C., Lillis, C., LeMone, P., Lynn, P. (2011). Fundamentals of nursing: The art and science of nursing care (7th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &