Sunday, May 16, 2010

What is nursing terminology?

I've spent a semester studying this and used some really great quotes to summarize what they are and why nursing must use terminologies to describe our work and bill appropriately for it. However, I believe Thede and Sewell state it most simply: "standardized terminology is a list of terms with agreed upon definitions so that when a term is used it means the same thing to everyone." This is even more important as electronic health records become the norm for patients.

Nursing care, contrary to popular belief, is not billed separately, as many specialties are, in your typical hospital bill. We fit right in there with the room rate and paper towels. While we work 24/7 to be the "eyes and ears" of your physician, who pops in and out, and actually do work ordered by them (which incidentally, is about 33-40% of your bill) and other folks, our work has yet to be specifically defined. Implementation of standardized terminologies and data sets aims to do this.

If after reading this little bit, you are still horribly confused, I highly recommend Thede and Sewell's book, Informatics and Nursing: Competencies and Applications. It's a great overall book to start with for any nursing and computers topic about which you might have questions.

Once you've read a few chapters and want to delve into the intricacies of what exactly those terminologies are, see the links below for the ANA(American Nurses Association) recognized terminologies.

NANDA-I (North American Nursing Diagnosis Association International)

Omaha System

CCC (Clinical Care Classification)

ICNP (International Classification of Nursing Practice)

NIC (Nursing Intervention Classification)

NOC (Nursing Outcome Classification)

PDNS (Perioperative Nursing Data Set)

SNOMED-CT (Systemized NOmenclature of MEDicine)

LOINC (Logical Observation Identifiers Names and Codes)

ABC codes (ABC Coding Solutions -formerly Alternative Link)

Enjoy your explorations of nursing terminology!

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