ANA-Recognized Standardized Terminologies (Coursework Sample)

ANA-Recognized Standardized Terminologies
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Regarding Bulechek, Butcher and Dochterman (2008), documentation of patient data is focused on providing a better insight to policy makers, patients and healthcare providers on how to make appropriate interventions. Health providers are asked to keep mandatory records of their patients for future reference and for curating interventions accordingly. Patient data also boosts the cost and quality of healthcare since the progress of the six care dimensions is accelerated. Documentation dwells on improving safety, efficiency, punctuality, equity, effectiveness and patient-centeredness.
On the other hand, data may be used by medical practitioners to determine the best therapeutic intervention. Data may also be used in cases of legal issues whereby malpractice is thought to have occurred. Laitinen, Kaunonen and Astedt-Kurki (2010) argue that data is considered a primary and an unbiased indicator of the patient’s health at a certain point.
Concept of Standardized Terminologies
A standardized terminology is viewed as a foundation through which integration of evidence-based guidelines may take place. At this moment, decisions can be made by rules that promote the manner in which evidence is deployed in patient care. Terminologies also work through coordinating healthcare, possessing documentation flexibility and measurement of quality. They are thus expected to support nursing practice through the use of unambiguous terms. In this context, data that is comparable, standard and consistent is generated (Bulechek, Butcher and Dochterman, 2008).
ANA-recognized standardized terminologies
Some of the current classifications include NOC, NIC, NANDA, Clinical Care, Omaha System, LOINC, SNOMED CT. NANDA is categorized into thirteen domains of nursing practice with forty-six classes. Some of the 201 nursing diagnoses available include activity intolerance and ineffective individual coping. The Nursing Intervention Classification (NIC) has seven domains including community, health system, family, and safety, behavioral, physiologic complex and physiologic basis.
NIC has thirty classes and 542 interventions whereby each intervention is made up of non-coded defining activities. The NOC (Nursing Outcomes Classification) has seven outcome domains including physiologic health, functional health, perceived health, family health, community health amongst others. NOC has 29 classes with 385 patient states. The Omaha system has 40 client problems with four domains namely: psychosocial, physiological, and environmental and health-related behaviors.
Omaha has 62 nursing interventions with an outcome scale for problem ratings. The CCC (Clinical Care Classification) has 172 nursing diagnoses further divided into twenty categories. CCC contains 201 nursing interventions that are classified into four kinds of actions such as manage/coordinate, teach, care/perform and assess/monitor. It also includes stabilized, deteriorated and improved as the three goals linked with the diagnosis statement. AORN, on the other hand, deploys a subset of diagnoses from NANDA to give 29 outcomes and 133 interventions (Moorhead et al., 2008).
Application issues
Regarding Moorhead et al. (2008), there remains much criticism on the level of separate training required to understand the documentation system. It also becomes difficult for a nurse to focus critically...