Standardized Nursing Language By Candidate’s Name 2012 FACULTY OF HEALTH SCIENCES, COLLEGE OF NURSING Abstract The use of standardized nursing language for electronic documentation enhances communication between nurses and other health care professionals to present improved patient care, adherence to standards and increased visibility of treatment…
Thus, it makes strategic sense for all hospital departments, including the Accident and Emergency (A&E) unit within a hospital, to maintain electronic patient record systems, which present clinical and nursing notes, patient data, treatment history, etc. to assist with care. Life and death decisions in the A&E unit within a hospital are quick and clear and legible information is essential to administer proper treatment. This project report presents a discussion about electronic patient record systems that incorporate standardized nursing language for the A&E unit within a hospital. Consideration of the Keogh Medical Systems Electronic Patient Record System, the Ascribe Symphony system and the Siren ePCR that enables information collection in ambulances concludes that the ideal electronic patient record system for an A&E unit within a hospital combines the Ascribe Symphony system and the Siren ePCR system. This combination presents a capacity for timely information flow right from first contact with a patient. (This page intentionally left blank) Introduction McGonigle and Mastrian (2011) suggest that the use of informatics in healthcare is increasing because a need exists for adequate knowledge about the progression of various ailments for application of the right therapy. Thus, nursing professionals are now information dependent knowledge workers who must maintain accurate nursing records in information systems for accurate depiction of the care process and the results presented by this. However, it is impossible for medicine, nursing or any other healthcare related discipline to present accurate electronic records without resorting to a standardized language or vocabulary that accurately depicts the real-life condition of a patient at any point in time. According to Rutherford (2008), doctors, nurses and other health professionals should be able to read a record for a patient, maintained as an electronic document, to seek an accurate assessment of the situation without getting confused about what really transpired. Knowledge imparted by accurate records benefits care because everyone knows what happened without ambiguity to decide about what needs doing. However, any inaccuracies result in confusion that presents an adverse impact on the delivery of appropriate care for a patient. Thus, nursing information systems that maintain computerized electronic records based on the standardized nursing language are now essential for hospitals in which a wide variety of health professionals must make the right decisions at all times based on these records to deliver the most appropriate care for a large number of patients. According to McGonigle and Mastrian (2011), nursing informatics systems should permit for accurate knowledge acquisition for the health situation for patients, precise knowledge processing, knowledge dissemination without any adulteration and accurate knowledge generation. However, if depiction of information in a nursing informatics system presents flaws, the nursing informatics system is likely to present errors. This adds to the impetuous for ensuring accurate transcription of electronic records into the system, and the standardized language ensures that this is possible. Rutherford (2008) states that ...
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