Standards Terminology Paper Nursing Intervention...

Standards Terminology Paper Elizaveta Pavlenko Frostburg State University Preface In standards terminology paper one patient’s assessment will be presented along with Nursing Diagnosis, Nursing intervention Classification and the Nursing Outcome Classification. In conclusion part of the paper, the summary of these systems will be provided. Clinical Encounter Mary Smith, Female, 56 years old, presented to Emergency Department with abnormal Chest Xray, fever, chills and generalized weakness on Friday, 10/31/2014. Per patient, she came to visit her physician after she started feeling abnormally tired at work. After consult, physician ordered Chest Xray that showed bilateral infiltrates in lungs. Given previous lung disease history, and history of COPD, physician suggested a visit to a local Emergency Room, after which Mary Smith was admitted to an outpatient unit for observation. Additional investigation of past medical history revealed that patient has Chronic Pneumonia due to Mycobacterium Avium Complex and Gastroesophageal reflux disease. Admission history revealed that Mary Smith lives with her spouse and work in a local retail store. Patient denied smoking history, alcohol consumption history, drug use history. Psychosocial assessment revealed that patient’s house was burglarized few months ago, otherwise no o ther stressful factors added. Patient presented with no known allergy history. Current medication assessment showed that patient takes probiotics,Show MoreRelatedIntroduction. This Paper Provides A Discussion Of The Electronic1523 Words   |  7 PagesIntroduction This paper provides a discussion of the Electronic Health Record for healthcare, explains why it is important for nursing to have a standard nomenclature for nursing care, and compares and contrasts two of the nursing terminologies currently recognized by the American Nursing Association. Body Organized information allows inferences to be made that answer questions greater than those answered by the information alone. (Moss, Damrongsak, Gallichio, 2005, p. 545). Medical care isRead MoreStandardized Terminology Paper : Standards Terminology1738 Words   |  7 Pages Standardized Terminology Paper Tracy Bell Frostburg State University Running head: STANDARDIZED TERMINOLOGY PAPER 1 STANDARDS TERMINOLOGY PAPER 6 STANDARDIZED TERMINOLOGY PAPER 2 Standardized Terminology Paper Nurses every day work together as a team in implementing individual care plans specific to patient care to meet needs. For this reason nurses must use a language when documenting details of patient care that is universal and easily understood by others. This type of communicationRead MoreNursing Terminology System Vs. The International Classification Of Nursing Practice1208 Words   |  5 PagesNursing Terminology System Comparison Nursing terminology could be described as the formal and informal communication that occurs in a nurses daily activity. According to McGonigle Mastrian (2009) nursing terminology allows nurses to communicate nursing data, information and knowledge specific to nursing. In addition, standardized nursing terminology refers to a system. This means they have undergone approval by a specific authority. The American Nurses Association (ANA) is one authority with aRead MoreThe Need For Classification Of Nursing Data1559 Words   |  7 PagesThe Need for Classification of Nursing Data in EHRs In the healthcare industry, nursing is underrepresented in the development of healthcare policies. 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Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT) is one of many clinical terminologies currently in use for the purpose of documenting by healthcare professionals and specialists in Electronic Medical Records. The mapping of SNOMED CT has been validated for accuracy against multiple coding and diagnostic classification systems. A brief history of SNOMEDRead MoreThe International Classicfication of Nursing Practice in Electronic Health Record Provides a Standard Language for Assessments528 Words   |  2 PagesThe International Classification of Nursing Practice (ICNP) in the Electronic Health Record (EHR) provi des a standardized language for nursing assessment documentation. The ICNP is a standardized nursing language that promotes unity among existing nursing standards and demonstrates the nurses’ contribution to health care (McGonigle Mastrian, 2012). A term is known as a word or a phrase. Nursing terminology is a group of terms used to collect, represent, or communicate data and information collectedRead MoreStatistics Lab week 63858 Words   |  16 Pagesinformation relates to many people ambiguously. Settings are preset for a specific population and set of data fields and then sealed to prohibit tampering. CertBox technology de-identifies health information in accordance to the scientific standard of de-identification allowed under HIPAA. The resulting de-identified data is then shared with bio-terrorism surveillance systems. CertBox technology (more generally termed a â€Å"privacy appliance† by DARPA) allows us to certify that resultingRead MoreNursing Theory in Practice1092 Words   |  5 PagesNursing Theory In Practice Chamberlain College of Nursing NR 501: Theoretical Basis of Advance Practice September 25, 2011 Introduction Imogene King was the developer of both a Conceptual Framework and a Goal Attainment theory. The Goal Attainment theory is a middle-range theory that originated from the Conceptual System. The primary concepts of Goal Attainment theory are perception, communication, interaction, self role, grow and development, stress, and time and spaceRead MoreThe History of Healthcare Informatics2652 Words   |  11 PagesThe History Behind Nursing Informatics Jackie Bailey Colorado Christian University Prof. L. Rieg CIS312A: Final Paper September 26, 2012 The History Behind Nursing Informatics Nursing informatics (NI) has become a vital part of healthcare delivery and has become a defining factor in the selection, execution, and assessment of technology that supports safe, exceptional quality and patient-centered care. Nursing has become so uniform. The data in patient records has become a valuable