STANDARDIZED CODING SYSTEMS 1
TheImportance of Standardized Coding Systems
Standardized coding systems refer to the common terminology used indescribing assessments, outcomes, and interventions. Nurses need todocument care using a standardized language due to several reasons.Firstly, it leads to better communication among medical practitioners(Rutherford, 2008). For example, the International Classification ofDiseases (ICD-10) was developed by the World Health Organization(WHO) for billing purposes (Brown, 2011). Therefore, all institutionsare required to use the inpatient procedure codes when submittingclaims for hospital services. Notably, ICD-10-CM has been preferredsince it has an enhanced structure, flexibility, and capacity forincorporating advances in medical knowledge and technology (Brown,2011). A standardized language would also increase the visibility ofvarious nursing interventions. In this respect, most practitionersuse informal notes rather than care plans and patient records. Ratherthan focusing on recovery, such communication seeks protection fromlitigation (Rutherford, 2008). Therefore, using computerizeddocumentation systems will pinpoint the contribution made by nursesto patient outcomes.
Furthermore, standardized nursing languages would ensure that medicalfacilities manifest lower rates of readmissions. Hence, improvedpatient care would prevent the misuse of resources. For instance, allpractitioners would be encouraged to observe for cues of discomfort,perform an assessment of pain, and reduce the factors thatprecipitate pain (Rutherford, 2008). Moreover, adopting astandardized nursing language would enhance the data collectiontechniques used to analyze nursing care outcomes. Hence, it will bepossible to benchmark medical services across various medicalinstitutions (Rutherford, 2008). For example, the National Databaseof Nursing Quality Indicators (NDNQI) collects unit-specific andnurse-sensitive indicators, compares such data with other facilities,and sends the findings to the participating organization (Rutherford,2008). Granted, many institutions have embraced the use of healthrecords and electronic documentation (ED). Such databases havedeveloped national standards for the collection and analysis ofperformance data. Nevertheless, standardized coding systems wouldensure greater adherence to the guidelines of nursing care(Rutherford, 2008). The regulations adopted across health careorganizations have been developed by several expert practitioners.Therefore, other professionals can develop the necessary confidenceto trust and apply established standards. Such systems would alsohelp administrators of health care facilities to perform objectiveassessments of nursing competency (Rutherford, 2008). Organizationsare required to evaluate the professionalism of their medicalpersonnel. Consequently, standardized nursing languages can be usedto assess interventions and determine staffing needs.
The standardization of coding systems should be conducted in allnursing practice. In many instances, data can be synthesized usingcomputer systems to enable wisdom development (Matney et al., 2011).Nursing informatics can be developed such that similar standardsexist in all areas of practice. For example, the Nursing ManagementMinimum Data Set (NMMDS) can be used to reduce the burden onadministrators. Furthermore, it can enhance the significance ofelectronic health records within the system (Westra et al., 2010).Besides, standardized nursing languages such as the Diagnostic andStatistical Manual of Mental Health Disorders (DSM-IV) have been usedacross all nursing practice. In this regard, practitioners haveutilized established guidelines to classify different psychiatricconditions. Hence third-party payers and other stakeholders canunderstand the diagnosis made by other professionals. Othersignificant coding systems include the Nursing OutcomesClassification (NOC), Nursing Intervention Classification (NIC), andClinical Care Classification (CCC) (Rutherford, 2008). Such languageshave been used across several settings for many decades. Therefore,standardized coded systems should be implemented in all nursingpractice.
Brown, B. (2011). ICD-10-CM: What is it, and why are we switching?Journal of Health Care Compliance, 13(3), 51-79.
Matney, S., Brewster, P., Sward, K., Cloyes, K., & Staggers, N.(2011). Philosophical Approaches to the Nursing InformaticsData-Information-Knowledge-Wisdom Framework. Advances in NursingScience, 34(1), 6-18. doi:10.1097/ans.0b013e3182071813
Rutherford, M. A. (2008). Standardized Nursing Language: What Does ItMean for Nursing Practice? OJIN: The Online Journal of Issues inNursing, 13(1). Retrieved fromhttp://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Health-IT/StandardizedNursingLanguage.html
Westra, B., Subramanian, A., Hart, C., Matney, S., Wilson, P., &Huff, S. et al. (2010). Achieving "Meaningful Use" ofElectronic Health Records Through the Integration of the NursingManagement Minimum Data Set. The Journal of NursingAdministration, 40(7-8), 336-343.doi:10.1097/nna.0b013e3181e93994