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NR361 Week 3 Discussion Question, Standardized Terminology and Language in Informatics

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Week 3: Standardized Terminology and Language in Informatics (graded) 7777 unread replies.9292 replies. What is the impact of Centers for Medicare and Medicaid Services (CMS) payment denial on the healthcare system? • What are the implications for our nursing practice related to use of standardized terminology for documentation? • How do evidence-based practice guidelines impact patient outcomes and necessitate improved practice care? • Professor and class. • The impact of payment denial by Centers for Medicare and Medicaid Services (CMS) is that hospitals will be pressured to minimize readmissions due to hospital error, such as hospital-acquired infections. Previously, hospitals were reimbursed for providing services related to readmissions, even when the hospital itself was at fault. Under the payment denial system, hospitals have more incentive to maintain quality practices that lead to better care, and ideally fewer readmissions (Delbanco, 2014). This system is designed to promote the best outcomes for patients, as it essentially pressures the hospital to make fewer mistakes. • The implications of standardized terminology for documentation on nursing practice are that communication will be clearer, and there will be fewer mistakes made due to a misinterpretation of the documentation. Standardized terminology ensures that every nurse is taught to use specific words or terms that every other nurse will understand, regardless of where the care is provided (Lundberg et al., 2012). This is very valuable regarding ensuring that all patient documentation is easily and readily understood by anyone who may be reviewing it. As a result, there will be fewer errors and mistakes in reviewing patient information, which will naturally result in fewer errors being made. • Evidence-based practice guidelines improve patient care because they are based on research that has already been conducted and reviewed. Evidence-based practice refers to policies or programs that rely on actual research, or evidence, rather than simply theory or assumption. For instance, evidence-based research might identify the best way to reduce patient falls, which will inform guidelines on policies related to patient falls. Because the research has already been conducted and the evidence has already been provided, guidelines relying on this research will be the most effective at their desired aim, which means the safest or most effective procedure will be recommended (DiCenso et al., 2014).   • References • Delbanco, S. (2014). Landscape: Non-Payments. Health Affairs. Accessible at • DiCenso, A., Guyatt, G., & Ciliska, D. (2014). Evidence-Based Nursing: A Guide to Clinical Practice. Elsevier Health Sciences. • Lundberg, C., Warren, J., Brokel, J., Bulechek, G., Butcher, H., McCloskey Dochterman, J., ... & Spisla, C. (2012). Selecting a standardized terminology for the electronic health record that reveals the impact of nursing on patient care. Online Journal of Nursing Informatics, 12(2).

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