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NURS 6411:The Standardized Terminologies Applied to Health Care

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NURS 6411 Week 11: Standardized Terminologies Applied to Health Care essay assignment

NURS 6411: Information and Knowledge Management | Week 11 essay assignment

How important is it to use standardized terminologies and encourage collaboration in health care organizations?

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Imagine you are treating a patient who is expressing a problem with breathing. You carefully record in his chart that he has shortness of breath. After the doctor performs her exam, she states that the patient is suffering from dyspnea. When you discuss the case with a fellow nurse, she remarks that she has seen such cases before and it is certainly caused by abnormal breathing patterns. All three diagnoses actually refer to the same condition. The real problem occurs when the information is entered into a database. Which term should be used? Later, if you are trying to identify patients with similar conditions, would you miss some because of the varying terminologies?

Similarly, multiple health care organizations can each have specific data about a patient or illness, but unless the data terminology is standardized, the value of the database system is limited. This standardization is conducive to improving patient care and reinforcing productive communication between nurses, doctors, and other health care personnel.

This week, you familiarize yourself with the importance of standardized terminologies for data storage and retrieval. You also focus on the relationship between clinical information systems and standardized terminologies in database design.

Learning Objectives

Students will:

  • Assess the use of standardized terminologies in databases and clinical information systems
  • Analyze the importance of standardized terminologies for data retrieval

Have you ever traveled abroad and asked for directions from someone who did not speak your own language? Perhaps you unsuccessfully attempted to use Google Translate or tried gestures and hand signals to communicate your request. The ability to communicate in the same language greatly increases the likelihood of shared understanding.

In health care, having a standard terminology facilitates the flow of information. Just as two people who speak different languages have difficulty understanding one another, so will two databases that utilize differing sets of terminologies. Standardized, shared terminologies enable database systems to effectively communicate.

To prepare:

  • Review this week’s Learning Resources focusing on the significance of standardized terminologies in health care settings. Consider how standardized terminologies are important in the development and use of databases and clinical information systems.
  • Explore the websites of major health care organizations to determine their recommendations on acceptable standardized terminologies.
  • Determine the standardized terminologies currently used by your health care organization (or one with which you are familiar).
  • Consider the standard terminologies (recommended by a major medical organization or based on your experiences) you would like to see incorporated into your organization’s databases and clinical information systems. What would be the benefit of using these particular standards? How might this impact the quality of the information retrieved from databases within your organization?

By Day 3

Post a description of at least one standardized terminology that is recommended by a major health care organization. Assess how or if this terminology is incorporated into your organization’s databases and clinical information systems. Identify at least one additional standardized terminology you would like to see incorporated into the organization’s databases. Analyze the importance of incorporating this terminology and how this could impact the quality of the data retrieved from the databases. Justify your response.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days using one or more of the following approaches:

  • Ask a probing question, substantiated with additional background information, evidence, or research.
  • Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
  • Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
  • Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.

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