From your practice standpoint, what have you read this week in your text or in the lesson that offered a new view or appreciation for standardized terminology? Be specific. example attached Standardized Terminology TOP OF PAGE What are the reasons why nurses need to be concerned about standardized terminology? In many prelicensure nursing programs,  medical terminology  is a required course. If it is not required, it is certainly implied that nurses be able to speak “medical.” However, using standardized terminology as it relates to nursing practice is imperative so that we can communicate among each other, other disciplines, and those who review nursing outcomes or data and provide reimbursement for services provided. Benefits and Challenges of Standardized Terminology TOP OF PAGE Imagine a room filled with 13 people who are all speaking different languages with no means for translation. That is what it is like for a computer to try to connect various programs when each computer is using a different terminology. Hebda and Czar (2013) offer a detailed description of the need for standardized terminology in order to collect aggregate data. There have been many conversations over the years about the need for increased visibility of nursing activities. Nursing does not charge for individual services; therefore, patients do not see an accounting of specific nursing care that they received when they review their bills. Nurses go from one patient to the next, taking care of a multitude of needs, without documenting each and every activity or thought process for care coordination. Much of nursing care reflects the concept of data-to-wisdom that we discussed in Week 1, and it may not be documented as such. If nursing data are to be visible, nursing activities must be retrievable, and for them to be retrievable, nursing concepts and activities have to be integrated into a Clinical Information System (CIS) or Health Information System (HIS) by using a language. That language must speak to other languages in the system, such as finance, resource management, and interdisciplinary and multidisciplinary partners. For example, we know that oral hygiene is an important personal care activity for our patients. If we want to be able to capture the nursing time, money, and resources spent on oral hygiene, first we have to be able to designate a category (personal hygiene), and then a term (oral care) that all system components are able to read.  Part of managing technological change as defined by Lorenzi and Riley (2010) is the understanding of unique aspects of nursing informatics and its application to the healthcare practice environment. A function of nurses in all practice settings is a commitment to change that is evidenced across nursing specialties and practice environments (Morrison & Symes, 2011). It is important that the nurse become familiar with nursing informatics language because it will increasingly be used in the future, particularly when it c.

1. From your practice standpoint, what have you read this week in
your text or in the lesson that offered a new view or
appreciation for standardized terminology? Be specific.
example attached
Standardized Terminology
TOP OF PAGE
What are the reasons why nurses need to be concerned about
standardized terminology? In many prelicensure nursing
programs,
medical terminology
is a required course. If it is not required, it is certainly implied
that nurses be able to speak “medical.” However, using
standardized terminology as it relates to nursing practice is
imperative so that we can communicate among each other, other
disciplines, and those who review nursing outcomes or data and
provide reimbursement for services provided.
Benefits and Challenges of Standardized Terminology
TOP OF PAGE
Imagine a room filled with 13 people who are all speaking
different languages with no means for translation. That is what
it is like for a computer to try to connect various programs
when each computer is using a different terminology. Hebda and
Czar (2013) offer a detailed description of the need for
standardized terminology in order to collect aggregate data.
There have been many conversations over the years about the
need for increased visibility of nursing activities. Nursing does
not charge for individual services; therefore, patients do not see
an accounting of specific nursing care that they received when
they review their bills. Nurses go from one patient to the next,
taking care of a multitude of needs, without documenting each
and every activity or thought process for care coordination.
Much of nursing care reflects the concept of data-to-wisdom
that we discussed in Week 1, and it may not be documented as

2. such.
If nursing data are to be visible, nursing activities must be
retrievable, and for them to be retrievable, nursing concepts and
activities have to be integrated into a Clinical Information
System (CIS) or Health Information System (HIS) by using a
language. That language must speak to other languages in the
system, such as finance, resource management, and
interdisciplinary and multidisciplinary partners. For example,
we know that oral hygiene is an important personal care activity
for our patients. If we want to be able to capture the nursing
time, money, and resources spent on oral hygiene, first we have
to be able to designate a category (personal hygiene), and then a
term (oral care) that all system components are able to read.
Part of managing technological change as defined by Lorenzi
and Riley (2010) is the understanding of unique aspects of
nursing informatics and its application to the healthcare practice
environment. A function of nurses in all practice settings is a
commitment to change that is evidenced across nursing
specialties and practice environments (Morrison & Symes,
2011). It is important that the nurse become familiar with
nursing informatics language because it will increasingly be
used in the future, particularly when it comes to meaningful
use, which is a term discussed in another lesson. Nurses benefit
from establishing relationships with an informatics nurse
specialist who serves in one of the many roles emerging in this
specialty.
Reflection
Reflect on the nursing language that you use in your practice. Is
the language shared by practitioners outside of your
organization, in other words, do you speak the same language as
your peers, perhaps in a different practice setting? If not, has
this caused any problems with communication?
A systematic approach to naming is known as a nomenclature.
Such terms are typically described according to a pre-
established set of rules. Examples of nursing nomenclatures
important to practice include SNO-MED and ICNP© (Coenen &

3. Kim, 2010).
Informatics nurse specialists have documented current efforts
toward meeting the demand for a reference terminology of
nursing concepts. These specialists are building on the
foundation of existing interface and administrative
terminologies, and are collaborating with efforts to develop
terminology across the spectrum of healthcare. Such efforts
address the “languages” spoken by nurses in a variety of
practice settings. These include but are not limited to
NANDA - North American Nursing Diagnosis Association;
NMDS - Nursing Minimum Data Set;
HHCC - Home Healthcare Classification;
OMAHA system, used in home care, hospice, public health, and
prisons;
NIC/NOC - Nursing Interventions Classification (NIC)/Nursing
Outcomes Classification (NOC); and
PCDS - Patient Care Data Set.
Let’s look at each language in more detail.
NANDA
. The North American Nursing Diagnosis Association (NANDA)
was first developed in 1950, and to date has grown to include a
multitude of diagnoses (Whitley, 2009). Prelicensure nursing
education programs often include nursing diagnoses in their
curricula and serve as the basis for writing nursing care plans.
NMDS
. The Nursing Minimum Data Set (NMDS) was first explained in
1972 through nursing research at the University of Iowa and
included a focus on nursing diagnoses, nursing interventions,
nursing outcomes, and intensity of nursing care (Fetter, 2009c).
The NMDS evidences support for the notion that health and
nursing informatics encompasses pivotal roles of data and
information. NMDS identifies and documents essential data
using nursing vocabularies and ensures adequate computer-
based patient record systems. Through NMDS, nursing data,
information, and knowledge is accessed and built using
telecommunications to support care delivery and empowering

4. the consumer through health informatics. NMDS transforms
education and enhances nursing decision making through
national research agendas.
HHCC & OMAHA
. The Home Healthcare Classification was developed by Saba in
1991 and includes a multitude of nursing diagnoses and
interventions, while the OMAHA system was developed in 1992
and includes numerous problems with interventions and
outcome measures pertinent to community health. Informatics
nursing specialists suggest that the adequacy and usefulness of a
proposed-type definition for nursing activity concepts is
necessary for representing nursing activity concepts within a
concept-oriented terminological system (Lundberg et al.,
2008).
NIC/NOC
. The Nursing Intervention Classification (NIC) and the Nursing
Outcomes Classification (NOC) systems were first developed in
1987, with numerous interventions represented for the NIC as
well as numerous outcomes represented across a variety of
domains and classes for the NOC. In exploring NIC/NOC, note
that the attempt to produce a scientific classification of nursing
work represents one important direction for building nursing
knowledge. At the same time, it represents a significant strategy
for defending the profession of nursing.
PCDS
. The Patient Care Data Set (PCDS) encompasses patient
problems, patient care goals, goal evaluation, and patient care
orders. According to Lake, Moss, and Duke (2009), there is a
need to seek consensus on a common approach to the
development of nursing terminology standards for use in
information systems.
The aforementioned nursing languages are not the only ones.
Hebda and Czar (2013, p. 304) provide a comprehensive listing
of ANA-recognized nursing languages.
Table 15-5 ANA Recognized Nursing Languages
Terminology

5. Web site
Diagnosis/Problem
Intervention
Outcome
Other
Alternative Billing Concepts (ABC Codes)
http://www.abccodes.com
Billing Codes
Clinical Care Classification (CCC)
http://www.sabacare.com
X
X
X
International Classification of Nursing Practice (ICNP)
http://www.icn.ch/icnp.htm
X
X
X
Assessment
Logical Identifiers Names and Codes (LOINC)
http://loinc.org/
X
Assessment
North American Nursing Diagnosis International (NANDA-I)
http://www.nanda.org
X
Nursing Intervention Classification (NIC)

6. http://www.nursing.uiowa.edu/cnc/
X
Nursing Outcomes Classification (NOC)
http://www.nursing.uiowa.edu/cnc/
X
Nursing Management Minimum Data Set
http://www.nursing.umn.edu/ ICNP/USANMMDS/home.html
Nursing Management Codes
Nursing Minimum Data Set
http://www.nursing.umn.edu/ICNP/
Omaha System
http://www.con.ufl.edu/omaha
X
X
X
Perioperative Nursing Data Set (PNDS)
http://www.aorn.org
X
X
X
SNOMED-CT

7. http://www.ihtsdo.org/snomed-ct
X
X
X
HEBDA, TONI LEE; CZAR, PATRICIA, HANDBOOK OF
INFORMATICS FOR NURSES & HEALTHCARE
PROFESSIONALS, 5th Edition, © 2013. Reprinted by
permission of Pearson Education, Inc., Upper Saddle River, NJ.
Reimbursement Issues
TOP OF PAGE
As we have become more and more aware, properly documented
nursing care drives reimbursement in our various practice
settings. Using proper terminology and capturing nursing’s
unique contributions to healthcare is of the utmost importance.
No discussion of reimbursement is more important than the tie
between nursing care and patient satisfaction.
Nurses are held to a very high standard of care, and one way
that care is being rated is by HCAHPS. Nurses in acute care
settings may be familiar with Hospital Consumer Assessment of
Healthcare Providers (HCAHPS), which is a standardization
survey that collects data for measuring patients’ hospital
experiences. Many hospitals and health systems follow these
standards to help improve the quality and safety of patient care.
Do you know that HCAHPS scores can be accessed on their
website for recommendations of the best- or worst-scoring
hospitals within your area?
According to the Centers for Medicare and Medicaid Services
(CMS, 2013), three broad goals have shaped HCAHPS. To begin
with, the survey is designed to produce data about a patient’s
perspective of care that allows for objective and meaningful
comparisons of hospitals on topics that are important to
patients. Secondly, public reporting of the survey results creates
new incentives for hospitals to improve quality of care. And
finally, public reporting serves to enhance accountability in
healthcare by increasing transparency of the quality of hospital

8. care provided in return for the public investment.
Reflection
Should patient satisfaction scores be linked to reimbursement?
What “little things” can you do to improve patient satisfaction
that may eventually impact reimbursement?
Summary: Check Your Knowledge
TOP OF PAGE
Transcript
References
TOP OF PAGE
Coenen, A., & Kim, T. (2010). Development of terminology
subsets using ICNP.
International Journal of Medical Informatics
,
79
(7), 530–538.
Fetter, M. (2009b). A language of precision.
Issues in Mental Health Nursing
,
30
(2), 133–134.
Hebda, T., & Czar, P. (2013).
Handbook of informatics for nurses & healthcare professionals
(5th ed.). Boston, MA: Pearson.
Lorenzi, N. M. & Riley, R. T. (2010).
Managing technological change: Organizational aspects of
health informatics
. New York, NY: Springer Publishing Company.
Lundberg, C., Brokel, J., Bulechek, G., Butcher, H., Martin, K.,

9. Moorhead, S., & ... Giarrizzo-Wilson, S. (2008). Selecting a
standardized terminology for the electronic health record that
reveals the impact of nursing on patient care.
Online Journal of Nursing Informatics
,
12
(2).
Morrison, S. M., & Symes, L. (2011). An integrative review of
expert nursing practice.
Journal of Nursing Scholarship
,
43
(2), 163–170.
Perkins, S., & Larson, G. (2010). Navigating ICD-10: How to
get from point A to point B.
Health Management Technology
,
31
(12), 1–7.