Nursing Documentation Analysis

Documentation versus Patient Data Utilization

The primary focus of patient care documentation is to support information flow to promote care safety and quality. Documentation ensures a uniform presentation of structured information using paper-based or computer-based methods. Nurses utilize standardized documents to collect each patient’s demographic information, medical history, socioeconomic variables, and family history, among others (Leiner, Gaus, Haux, Knaup-Gregory & Wagner, 2003). In addition, electronic documentation supports data integration, which allows nurses to access patient information from different departments of a medical facility.

Documentation is also useful in clinical data management. Patient assessment relies on standardized documents that contain clinical facts about a condition. According to Leiner et al. (2003), the clinical documents typically used for patient evaluation include “history sheets, clinical examination reports, nursing care charts, discharge summaries, and lab reports” (p. 76). The documents are utilized in patient care planning, disease prognosis, and review of the care already received. Clinical records also facilitate agency accreditation and billing. Therefore, documentation is not only useful in patient-oriented analysis, but it also supports external reporting to facilitate reimbursement, quality management, and accreditation.

Standardized Terminologies

Clinicians use terms to describe concepts in nursing practice. According to Cimino (1998), standardized healthcare terminologies are defined by the following twelve concepts:

  1. Content – it is the subject matter of a terminology. By focusing on the content of a terminology, users can detect and avoid errors of omission.
  2. Concept orientation – a concept in the medical vocabulary is unambiguous, i.e., it is not subject to two or more interpretations.
  3. Permanence – the interpretation attached to a concept is permanent.
  4. Poly-hierarchy – concepts can be placed in multiple classifications or locations.
  5. Code identifier – concepts are assigned distinctive codes to aid in classification and exploration.
  6. Formal definitions – each concept has a conventional definition.
  7. No residual classes – the classifications are fixed, i.e., they do not include additional concepts.
  8. Multiple granularities – practitioners utilize different terms to express the same concept in detail.
  9. Multiple consistent views – users hold different, but consistent views on the functional classifications of a standardized vocabulary.
  10. Representing context – the meaning of a concept depends on the context in which it is used.
  11. Graceful evolution – standardized terms should accommodate conceptual changes in medicine.
  12. Non-redundancy – a concept should be represented in a standardized terminology in only one way.

The Role of the American Nurses Association

The American Nurses Association (ANA), through the Committee for Nursing Practice Information Infrastructure, evaluates new standardized terminologies for use in nursing practice. The committee’s evaluation criteria dictate that the “data set, classification, or nomenclature” must support clinical practice through useful standardized vocabularies (Rutherford, 2008, p. 42). In addition, the terms must be unambiguous and validated through implementation in a documentation system in a facility. The committee also requires developers to maintain and revise the terminologies on a regular basis.

A second role of the ANA is to oversee the execution of a terminology by the developer. The agency, through the Nursing Information and Data Set Evaluation Center (NIDSEC), approves standardized languages that support clinical documentation. A candidate terminology must also be interoperable with other clinical systems, such as the computerized patient record system (CPR) (Rutherford, 2008). ANA also evaluates the security, confidentiality, and data storage and retrieval aspects of the terminology before approving it. The agency currently recognizes 12 standardized terminologies in use.

ANA-recognized Standardized Systems

The ANA-recognized standardized terminologies include, “NANDA, NIC, NOC, the Clinical Care Classification (CCC), Omaha System, AORN Perioperative Data Set, International Classification of Nursing Practice (ICPN), SNOMED CT, LOINC, NMDS, NMMDS, and ABC Codes” (Rutherford, 2008, p. 43). Of the 12 systems, CCC, NANDA, ICPN, NOC, and NIC define nursing diagnoses, treatments, and patient outcomes. However, the number of diagnoses, interventions, and goals defined differ between them. For instance, the number of diagnoses for NANDA, CCC, and NOC is 201, 176, and 385, respectively. On the other hand, the Omaha system, CCC, and ICPN contain terms that define nursing problems, treatments, and goals.

SNOMED CT is highly interoperable with EHR records and allows mapping of related terminologies, while AORN Perioperative Data Set utilizes NANDA diagnosis data. In addition, all the language systems require royalty payments except CCC and the Omaha System (Rutherford, 2008). Most US institutions can use SNOMED CT and LOINC free of charge.

Implementation Issues Related to Nursing Standardized Terminologies

One of the issues pertinent to the implementation of standardized terminologies in nursing is training. The successful use of a standardized terminology in a paper-based or computer-based documentation would require training on the nursing classification system of the language. A second issue relates to the place of clinical judgment in the system. Rutherford (2008) notes that the list of terms provided in a terminology is not a replacement for evidence-based practice. Thus, the nurse must evaluate the interrelationships between concepts in making clinical decisions.

The implementation of a new terminology also requires nurses to learn the terminology and the associated concepts. Learning the terminology enriches individual expertise, which leads to better clinical judgment. Nurses must also learn hypothesis testing and concept validation to use a standardized terminology effectively.

The Benefits of Using a Standardized Terminology

  1. It improves information flow among nurses, physicians, and managers of healthcare agencies.
  2. It enhances the “visibility of nursing interventions”, including clinical procedures and decisions (Rutherford, 2008, p. 45).
  3. The utilization of a standardized nursing terminology improves patient care. For instance, the use of symptom severity indicators can improve pain management in pediatric patients.
  4. The implementation of a standardized nursing terminology enhances clinical data collection for quality improvement purposes. The system provides consistent records that can be utilized to assess the quality of health outcomes associated with a particular intervention (Rutherford, 2008).
  5. The implementation of a standardized terminology enhances compliance to the standards of care. The terminology incorporates the standards of care recommended by professional nursing bodies.
  6. Nursing competency assessment – According to Rutherford (2008), a nurse’s performance in the interventions defined in the terminology determines his or her competency level.

The Function of the Unified Medical Language System

The Unified Medical Language System (UMLS) combines various “terminologies, classifications, and coding standards” to develop an interoperable system (U.S. National Library of Medicine, 2015, para. 3). UMLS is useful to vendors developing interoperable programs, e.g., EHRs, classes, and standardized terms. UMLS is a powerful tool for connecting clinical information, including medical vocabularies, drug identifiers, and billing codes, between systems (U.S. National Library of Medicine, 2015). Using UMLS, the relations between codes used by the physician, the pharmacy, and the insurer can be established. In addition, UMLS facilitates patient care coordination in a facility. Other key functions of UMLS include data mining, external reporting, and epidemiological research.

References

Cimino, J. (1998). Desiderata for Controlled Medical Vocabularies in the Twenty-First Century. Methods of Information in Medicine, 37(4), 394-403.

Leiner, F., Gaus, W., Haux, R., Knaup-Gregory, P., & Wagner, G. (2003). Medical Data Management: A Practical Guide. New York: Springer.

Rutherford, M.A. (2008). Standardized Nursing Language: What Does It Mean for Nursing Practice?. The Online Journal of Issues in Nursing, 13(1), 42-47.

U.S. National Library of Medicine. (2015). Web.

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