How might standards impact the documentation processes of your setting?

 

To prepare:

  • Review the references below and get the ideas from each.
    • How does each provide a framework to align the terminologies and data sets used in health care settings?
  • Reflect upon your current health care setting.
    • Does your setting currently use any of the standards outlined by a specific organization? Why?
    • How might standards impact the documentation processes of your setting? Furthermore, which standards might most apply to you in your work as a nurse?

Note: If you are not currently working in a health care setting, select a setting with which you are familiar for this Discussion.

By Day 3

Post a description of the health data standards your setting uses and how these standards impact documentation and your specific nursing role. Explain how standard development organizations impact your health care setting.

Pls get the ideas from this resources/references…

1. Saba, V. K., & McCormick, K. A. (2015). Essentials of nursing informatics (6th ed.). New York, NY: McGraw-Hill.

  • Chapter 15, “The Practice Specialty of Nursing Informatics”In this chapter, the authors explore the connections between various informatics specialties, such as health care informatics and nursing informatics. Focusing primarily on nursing informatics, the chapter provides information on its concepts, establishment, and practice.
  • Chapter 7, “Health Data Standards: Development, Harmonization, and Interoperability”This chapter explains the components that are necessary for health data standards to function effectively. Guidelines for interpreting health data standards are also given.

2. Bokur, D. (2012). To ‘EACH’ its own incentive payment: New CCHIT program rewards groups with EHR systems. MGMA Connexion, 12(2), 33–34.

3. Heymans, S., McKennirey, M., & Phillips, J. (2011). Semantic validation of the use of SNOMED CT in HL7 clinical documents. Journal of Biomedical Semantics, 2(Suppl. 3), 2–17.

4. Kim, W., Lim, S., Ahn, J., Nah, J., & Kim, N. (2010). Integration of IEEE 1451 and HL7 exchanging information for patients’ sensor data. Journal of Medical Systems, 34(6), 1033–1041.

5. http://www.phdsc.org/standards/health-information/…

 
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