What structured terminology do you use in your clinical practice?
In the emergency department all nurses work under the standards and scope of care in their related to their licensure within the state they work. All patients are triaged and assess by a registered nurse before having a medical screening by the Emergency room physician. Nurses use the NANDA for evaluating needs of of the patient and interventions to include a positive outcome and evaluate the effectiveness of the plan.
The nurse collects the data and information which includes pertinent information about medications, orders and decision making of the MD and it is placed in a structured charting system, and "free texting" if needed. The information is all placed in a electronic medical record. The procedure and diagnostic coding is coded after the physician is completed with the chart by medical records.
How are structured/coded clinical data useful in promoting quality patient care?
The structured/coded clinical data that is collected in the Emergency Room can be electronically sent to the PCP and evaluated to determine continued care for the patient. Hopefully the information flow from the clinical care area has good clarity so that the follow up physician understands what has been done for the patient and the follow-up care that is needed.
This information can increase health information and support evidence-based practice (PP. Fund. 2).
Lauri Morgan
3 comments:
Thank you. How do you find working with NANDA? (Many nurses find it feels "artificial"). Just curious...
Lauri
Looking at the picture of the horses, it looks like Lyman area Wyoming. Anyway, it sounds like you are grasping the computer charting well. I know at first it took me awhile to really know it. And still don't. Working agency and moving to different facilities, I had to learn about 4 different systems and keep them straight. But once I got it, it was all ok.
LuAnn Curtis
Kathy,
We have to use something to guide our practice, we can't just do everything from the hip (just a expression). I think it is important to goals, interventions and outcomes. How can we determine if we are following standards of care and quality of care for the patient.
Lauri Morgan
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