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Data Integrity and Standardized Nursing Languages

Information gathered by a healthcare team has a significant impact on a client’s care, and the integrity and accuracy of this data are obligatory. Software and hardware enable the workers to check, manage and store the electronic records. Standardized nursing languages prevent possible misinterpretations of data collected using different methods or theories.

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As cited in Lofstrom & Joyce (2006) Bakken, Cimino, & Hripcsak (2004) noted that nursing informatics “Addresses the management and processing of data, information, and knowledge to support nursing practice and the delivery of care”. The contemporary level of computer science development provides an opportunity for enhancing the accuracy of storage and management of the patients’ data but requires the computer proficiency of the personnel. The computer-based programs for managing the clients’ information enable medical workers to extract pieces of meaningful information from extensive data of medical reports. On the condition that the integrity of the data is preserved, the software might simplify the process of gathering the clients; information and enhance the effectiveness of the nurses’ work. For example, traditionally nurses record the medical reports using the narration, while computer-based programs could provide specialized menus for choosing the necessary diseases and symptoms instead of wasting time putting down the words that are significant for further planning of the clients’ healthcare, but can be omitted using charters and tables. Choosing one or several variants from the list of all available symptoms, the nurse economizes time and can concentrate on communication with the patient. The negative impact of the human factor is minimized as no questions would be accidentally omitted filling in the electronic charts as well as the problem of illegible handwriting may be disregarded. All questions on the tables that may seem to be insignificant to the patient or nurses need to be answered carefully. For example, even a client’s allergy observed only at an early age without any further presentations need to be recorded carefully and have an impact on the progress of the illness. The patient and medical workers could ignore the fact, but if this information is entered into the computer-based program, it is stored, processed, and taken into consideration for planning healthcare.

Another important advantage of Electronic Health Records (EHR) is the availability of data from different ancillary services. In Mitre Corporation research (2006) it was noted that “Most commercial EHRs are designed to combine data from the large ancillary services, such as pharmacy, laboratory, and radiology, with various clinical care components (such as nursing plans, medication administration records, and physician orders)” (p. 6). The customized interface of the EHR programs allows accessing the data from the related spheres, quick and uncomplicated management of information. The administrative system components may be used in only one institution, including numerical or alphabetical identification of the clients, while the laboratory system components are universal and help to avoid misinterpretations. For example, testing blood the customer is numbered for the nurses’ convenience, and this number is significant for the workers of only one clinic. The laboratory system components are recorded using the standardized nursing languages and can be used for the following planning of the client’s healthcare by the workers of other institutions.

The integrity of the information gathered by the nursing team has a significant impact on the clients’ healthcare. To avoid misinterpretations and minimize the negative impact of the human factor, the contemporary computer-based methods of systematizing the data and standardizing the terminology are to be used.

Reference List

Lofstrom, J. & Joyce, S. (2006). Ambulatory Informatics Nurses – Translating the Language of Patient Care. Health Publications. Web.

Mitre Center For Enterprise Modernization. (2006). Electronic Health Records Overview. Web.

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