The health care sector has undergone many changes in the past few decades. One of the significant policy changes is the requirement to keep electronic patients records. Electronic health records need to be uniform in order to enhance care by promoting sharing of health records across different facilities. Before the Health Information Technology for Economic and health Act, electronic health records were not adopted or used meaningfully.
Every nursing specialty field had its own coding language for writing health records. The challenge of implementing electronic health records successfully is having a uniform coding language. Documentation of care offered allows for a meaningful medical history to be constructed (Waneka & Spetz, 2010). From the documented care, nurses can easily determine vital information such as allergies and previous treatments regarding the information.
Since a patient can visit other health facilities, nursing care documentation should be done in a standard language so that it can be understood by other nurses. Standardization should be uniform across all nursing fields. This is because patients often need care from various fields and new nursing subfields are evolving daily and if every field adopts its standard language, the generated electronic health records would be of little use. Additionally, modern nursing care is based on an interdisciplinary approach (Komatsu et al., 2011).
A standardized nursing language across all nursing fields would enhance communication between different members of an interdisciplinary team. For instance, in my nursing practice, a nurse leader needs to communicate with nurses from various specialties when heading an interdisciplinary team. It is easier for the nurse leader to communicate the patient’s data using a standard nursing language. Further, Paans et al., supports the use of standard nursing language because its use increases the accuracy of health records.
References
Komatsu, H., Nakayama, K., Togari, T., Suzuki, K., Hayashi, N., Murakami, Y., & Ueno, N. T.
(2011). Information sharing and case conference among the multidisciplinary team improve patients’ perceptions of care. The open nursing journal, 5, 79.
Paans, W., Sermeus, W., Nieweg, R., & Van Der Schans, C. P. (2010). Prevalence of accurate
nursing documentation in patient records. Journal of Advanced Nursing, 66(11), 2481-2489.
Waneka, R., & Spetz, J. (2010). Hospital information technology systems' impact on nurses and
nursing care. Journal of Nursing Administration, 40(12), 509-514.
