Standardized Nursing Nomenclature: Now is the Time

Evolution in the delivery of healthcare and associated recordkeeping requirements add increased pressure for accurate and descriptive nursing documentation that can be understood across providers and healthcare settings.  Such antecedents include:

  • An increased emphasis on inter-professional models of care;
  • A shift towards value based care that efficiently produces high quality and positive outcomes;
  • Preliminary health information exchange between disparate components of a health care system;
  • Impending implementation of ICD-10 and the associated emphasis on nursing documentation that is congruent with ICD-10 and produces actionable information; and
  • The proliferation of health care delivery models emphasizing continuity and coordination of care.

With a long history of working towards development of a consensus model for standardized nursing, widespread adoption and consistent utilization of a standardized nursing language that provides complete, accurate and up-to-date patient information along with a single method for cross-mapping between assorted terminologies still eludes the profession.

Standardized Terminology and the EHR