A standard terminology is described as a common language, nomenclature or a classification that is designed to be shared among specific users. Standard terminologies have been widely used in the healthcare setting for accurately documenting client's assessment, care and outcomes as asserted by Häyrinen et al. (2010). Standard terminologies ensure that there is a commonly understood language among health care workers that can enable them to establish standards, influence policy making and expect funding for certain programs in the hospital. In nursing, use of standard terminologies is important in various ways. First, it is important in achieving mandated interoperability standards. It is also crucial in facilitating communication among nurses and other care givers in the hospital. Thirdly, it has made the collection of shared data possible which have enabled the adherence to standards of care and best practices. Finally, it also enables the measurement of outcomes in regards to patient management giving nurses better visibility to their work.
Example
Omaha System
The Omaha System is a standardized taxonomy that describes client’s care. According to Martin et al . (2011), it has three components that include the problem classification scheme, the intervention scheme, and the problem rating scale. The problem classification scheme is designed to provide structure and terms for the standardized assessment of individuals, families and the community at large. It is important to medical practitioners as they can collect, sort, classify, document, analyze and retrieve and communicate needs and strengths that are health related. The intervention scheme helps to describe multidisciplinary practices that are intended to prevent illnesses, improve health, decrease deterioration and to provide comfort before death. Medical practitioners use intervention scheme for the purposes of describing health related care plans and services to individuals. The problem rating scale is used to evaluate client progress throughout the service period. It measures the range of severity for the concepts of behavior, knowledge, and outcomes. The users of the Omaha system include nurses, doctors, occupational therapists, registered dieticians, and social workers. The Nursing Association in America has advocated for the use of the Omaha System since the year 1992. Tastan et al. (2014) pointed out that it has widely been used as an effective documentation tool for measuring outcome and quality of patients.
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I have been able to witness the use of standard terminologies in a hospital setting, and through that experience, I appreciated how the health care system had been digitalized. With the integration of computational science, information technology, and biomedical research, there is a learning health system which enables efficient delivery of care practices and the generation and application of new knowledge. Standard terminologies ensured that information from multiple locations such from the wards, laboratory, pharmacy, etc. could be searched, shared and synthesized whenever they were needed. One advantage that impressed me in my experience was how the application of standard terminologies supports research activities. Through interoperability and the use of common vocabulary that can be used by all, data can be easily acquired from the system which can then be computed and used for future decision making. The disadvantage that noticeable with this system is that it requires proper training to effectively understand and use the systems that come with the standard terminologies.
In conclusion, the transition from paper charting to electronic health records has magnified the need for standard terminology. The terminologies involve a language that is organized and approved and are utilized to represent and communicate data to develop an electronic health record. The nurses have benefited from this system as they can define patient problems, nursing interventions, and specific patient outcomes. Also, other members of the healthcare fraternity have been able to benefit from the terminologies as they can read them and form a necessary judgment.
References
Häyrinen, K., Lammintakanen, J., & Saranto, K. (2010). Evaluation of electronic nursing documentation—Nursing process model and standardized terminologies as keys to visible and transparent nursing. International journal of medical informatics , 79 (8), 554-564.
Martin, K. S., Monsen, K. A., & Bowles, K. H. (2011). The Omaha system and meaningful use: applications for practice, education, and research. CIN: Computers, Informatics, Nursing , 29 (1), 52-58.
Tastan, S., Linch, G. C., Keenan, G. M., Stifter, J., McKinney, D., Fahey, L., ... & Wilkie, D. J. (2014). Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review. International journal of nursing studies , 51 (8), 1160-1170.
