Compare and contrast any TWO nursing terminology systems and explain fully. Discuss why there is a need for codification of nursing data in EHRs. Include the basic concepts of the terminologies you selected and apply these to one case example from your own organization. You can provide an example from your practice or the literature. 500 words. 3 scholarly reference. Include introduction, conclusion and reference page in APA style. Include at least three (3) scholarly sources to support your claims.

Introduction

Nursing terminology systems are essential for the codification and standardization of nursing data in electronic health records (EHRs). EHRs play a vital role in healthcare settings by facilitating the documentation, storage, and exchange of patient information. In order to effectively capture and communicate nursing data, standardized terminologies are necessary. This paper will compare and contrast two nursing terminology systems, namely the International Classification for Nursing Practice (ICNP) and the Systematized Nomenclature of Medicine – Clinical Terms (SNOMED-CT). Additionally, the need for codification of nursing data in EHRs will be discussed, along with the application of these terminologies to a case example.

Comparison of ICNP and SNOMED-CT

The ICNP is a nursing-specific classification system developed by the International Council of Nurses, aiming to standardize nursing terminology worldwide. It is designed to represent nursing diagnoses, nursing actions, and nursing outcomes. The ICNP focuses on nursing phenomena, describing them in a structured manner and providing a comprehensive vocabulary for nursing data documentation. It allows for the identification of patient problems, interventions, and outcomes specific to nursing care. The ICNP is hierarchically organized into four levels: cluster, class, domain, and concept. For example, within the cluster “activity and exercise,” there is a class called “mobility,” which further includes concepts like “ambulation” and “transfers.”

On the other hand, SNOMED-CT is a comprehensive clinical terminology system that encompasses all areas of healthcare, including nursing. Developed by the International Health Terminology Standards Development Organization, SNOMED-CT is utilized to code and classify clinical information. It consists of a large number of concepts and relationships, allowing for precise and detailed representation of clinical data. SNOMED-CT is organized into hierarchies and has a rich network of relationships, enabling complex querying and analysis of clinical information. For example, it can capture not only the specific nursing intervention performed but also its context, such as the patient’s condition and the setting in which the intervention was carried out.

Despite their differences, both ICNP and SNOMED-CT share the common goal of standardizing nursing terminology. They aim to improve communication, interoperability, and data analysis in healthcare settings. However, their focus and scope differ. ICNP is dedicated solely to nursing, emphasizing the unique contribution of nursing care, while SNOMED-CT covers a broad range of clinical concepts and encompasses nursing as one of its domains.

The Need for Codification of Nursing Data in EHRs

The codification of nursing data in EHRs is crucial for several reasons. Firstly, standardized nursing terminologies improve the communication and understanding of nursing data among healthcare professionals. This enhances interdisciplinary collaboration and contributes to safer and more effective patient care. Secondly, codification facilitates the aggregation and analysis of nursing data on a broader scale, enabling evidence-based practice and research. Standardized terminologies allow for the extraction and comparison of data across different healthcare systems, leading to better insights into patient outcomes and healthcare delivery. Finally, codification of nursing data supports the documentation of nursing interventions and outcomes, providing a comprehensive record of the care provided to patients. This is particularly important for continuity of care, quality improvement, and legal purposes.

Case Example Application

Let us consider a case example of a patient admitted to a medical-surgical unit with a nursing diagnosis of impaired physical mobility. Using the ICNP, the nurse would document the related concepts such as “restricted ability to perform mobility tasks related to musculoskeletal impairment” and “decreased muscle strength.” The nursing actions documented might include “assisting the patient with ambulation” and “instructing the patient on range of motion exercises.” Additionally, the outcomes documented could include “patient able to ambulate independence using assistive device” and “patient able to demonstrate increased muscle strength.” By using the ICNP, the nurse can accurately capture and communicate the nursing care provided to the patient.

In contrast, if SNOMED-CT were used in the same case, the nurse would utilize the concepts and relationships within the terminology to document the nursing data. For example, the nurse might code the diagnosis of impaired physical mobility using the SNOMED-CT concept “20844004: Impaired mobility.” The nursing interventions would be coded using relevant concepts such as “442760005: Assistance with walking” and “229215003: Instruction on range of motion exercises.” The desired outcomes would be coded using concepts like “404127005: Independent walking using assistive device” and “38266002: Improved muscle strength.” SNOMED-CT allows for precise and granular coding of the nursing data, capturing in detail the assessment, interventions, and outcomes related to impaired physical mobility.

Conclusion

Standardized nursing terminologies, such as ICNP and SNOMED-CT, play a vital role in the codification of nursing data in EHRs. They enable effective communication, interoperability, and data analysis of nursing information. While ICNP focuses solely on nursing, SNOMED-CT encompasses nursing as one of its domains within a larger clinical terminology system. The codification of nursing data in EHRs is essential for improving patient care, research, and documentation purposes. By accurately documenting nursing diagnoses, interventions, and outcomes using standardized terminologies, nurses can ensure the delivery of safe, evidence-based care and contribute to the overall improvement of healthcare outcomes.

References:

1. Matney, S., Gephart, S., Staggers, N., Wilson, P., & Obeidat, R. (2011). Impact of standardized terminologies on EHR documentation. Journal of healthcare information management, 25(2), 37-45.

2. Bürkle, T., Combi, C., & Shahar, Y. (2016). A modular terminology reference model for clinical care, research and data integration: the EU-ADR project experience. Journal of biomedical informatics, 62, 330-346.

3. Bakken, S., Cimino, J. J., & Hripcsak, G. (Eds.). (2017). Promoting health IT standardization through the International Standardization Organization (ISO)/Technical Committee 215 “Health Informatics” (TC 215). IOS Press.