Nursing News

Electronic Documentation Calls for Standardized Nursing Language

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By Debra Wood, RN, contributor

Electronic documentation has called attention to the need for standardization of nursing terminology and ways to capture nursing interventions.

Marilyn E. Parker, Ph.D., RN, FAAN, is developing software that will help nurses electronically document their caring interventions.

“Nurses’ voice is a weak echo of the medical voice,” says Marilyn E. Parker, Ph.D., RN, FAAN, professor of nursing at the Florida Atlantic University (FAU) Christine E. Lynn College of Nursing in Boca Raton.

When Parker’s community nursing practice began shifting to an electronic record system, she realized there were places for nurses to record data, such as vital signs or medical symptoms, but no place for them to enter interactions and relationships with patients.

Parker, her colleagues and students are developing software to help nurses electronically document the caring aspects of what they do. She expects the FAU team will validate it this year.

“We want this software to show who is this person [the patient] as a person, not a gallbladder,” said Parker, adding that the software would incorporate what is important to the patient and his or her goals. She said software vendors and hospital nursing leaders have expressed interest in it.

“It’s finding a place for nursing’s voice to be heard,” Parker said. “I think we will be able to show the relationship between nursing caring and all that means and outcomes, because that’s how the money flows and people get paid.”

Carol J. Bickford, Ph.D., RN-BC, a policy fellow for the American Nurses Association (ANA) agreed, saying that vendors of electronic record systems focus on capturing data important for billing, reimbursement and mandated reporting.

“Nursing terminology has no dollars and cents attached and no mandated reporting,” Bickford said. “Part of the problem is nursing terminology is patient-centric—signs and symptoms we are attending to, what we are doing to attend to those. If we do it well, we make a difference, but no one pays anybody for that.”

Bickford said nurses have begun asking about how the work they do is captured electronically, so all providers can obtain a more complete picture of what is happening with the patient, but she acknowledges much opportunity exists for improvement.

Pat Feehery, RN, BS, CRNI, CNLC, maintains that a standard language that is understood by all disciplines will help to improve patient safety.

“There hasn’t been an appreciation of the contribution nurses make to the healthcare system,” Bickford said. “Describing what is going on with a person shouldn’t be determined by who is paying for what. You need a complete story, whether it is billable or not. It’s a mind shift we haven’t moved to.”

Giving everyone a better picture of what is happening with the patient is very important, agreed Pat Feehery, RN, BS, CRNI, CNLC, nursing informatics project manager at Sparrow Health System in Lansing, Michigan. She thinks technology will help standardize communication between disciplines, improve care and safety, and increase the amount of time nurses spend with patients.

Nurses, in collaboration with other professionals, helped build the electronic documentation system at Sparrow, based on evidence-based practice, and they customized some of the drop-down menus.

“It’s really important that everyone can look at the same picture,” Feehery said.

Pam Greene, Ph.D., RN, vice president of patient care services at The Menninger Clinic, a psychiatric center in Houston, Texas, also encouraged use of a standard language that all disciplines can understand to decrease risk of errors and improve communication.

The focus on quality outcomes necessitates a common language, so data extracted from different facilities reflects the same thing, added Nancy Brenan, RN, BSN, MBA, senior principal with the Noblis Center for Health Innovation in Washington, D.C.

“It will make nurses’ lives and work easier, if they have a standard language,” Brenan said. “And it will provide better care for the patients.”