Module 2- Structured Terminologies

Honestly, as a registered nurse working on my floor, I was unaware of structured terminologies. However, I have done some research and found out that they are, in fact, used. An RN case manager and a billing employee told me that the physicians who visit patients on the floor use the ICD-9 coding system, which ensures that their patients' insurance will be charged. Also, the case manager told me that they use a system called Interqual, which has a list of diagnoses and criteria that are applied to patients so that their insurance will process their claim. I also talked with an admissions employee, who said that when patients are admitted to the hospital, they (or a family member) fill out a form that includes all of the necessary data that the hospital requires (such as demographics, phone number, employment, an emergency number, etc.). Although the employee did not know of a name for this information, it is possible that this may be part of the nursing minimum data set. As far as structured terminologies that I use in my nursing practice, I use the NANDA terminology for nursing diagnoses. These nursing diagnoses are sometimes listed on the patients' cardex, and the nurses perform interventions based on these nursing diagnoses. I do not know of any place that they can be found in the new computer system that we have been using.
Structured clinical data can be useful in providing quality patient care because it promotes communication among the people who work for a specific patient. All of the care providers know something about the patient's background (such as with the minimum data set). Also, if all of the data is in structured terminologies, all providers "speak the same language" and can provide treatment while keeping in mind the various diagnoses and treatments the patient is experiencing.