Alphabet Soup: Standardized Language

Dee McGonigle, senior advisor and former editor-in-chief of the Online Journal of Nursing Informatics, asserts "informatics nurses are bilingual—they can talk IT and can talk nursing."

To understand informatics and it's role within nursing one must speak the language. In this post we will review two terminology systems to start your journey into the the language of informatics.

 

ICNP 

The International Council of Nurses (ICN) is an organization dedicated to the advancement of nursing and health worldwide through professional practice, regulation and social economic welfare. The ICN created a database of formal terminology for nursing to utilize to describe their practice through descriptions, diagnoses, and interventions. The database is referred to as the International Classification for Nursing Practice (INCP) and is intended to be used by nursing as the international terminology standard to improve data collection and communication in order to inform nursing practice, influence education, and shape policy.

 

SNOMED CT 

The Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) is also a resource of standardized and comprehensive clinical terminology. SNOMED CT was created by the College of American Pathologists and therefore is not nursing specific, however it is touted as the most comprehensive clinical vocabulary available. SNOMED is owned and maintained by The International Health Terminology Standards Development Organisation (IHTSDO) and the U.S. Federal Government is one of over 50 countries that recognize SNOMED CT as a standard for the exchange of health information. SNOMED CT is the basis for coding diagnoses and problem lists within the Electronic Health Record (EHR) to support interoperability and meaningful use; the language allows for consistent valuable communication and content that can be retrieved and processed for meaningful data.
In the video below you can see how SNOMED CT is used in the Emergency Department setting to utilize consistent, collectible, meaningful data in an EHR.

 

Why is a Standardized Language Important?

Leaders within the nursing community recognize the importance of a standardized language for nurses to achieve increased communication and professionalism as well as increased identification and collection of data related to interventions, care, and outcomes. The National Association of School Nurses' official position is that standardized language contributes to the advancement of care and research and therefore should be used in practice, EHR, and education. The American Nurses Association supports initiatives that develop a standardized nursing language and made the official recommendation to utilize recognized terminologies within clinical settings and SNOMED to document observations, interventions, and outcomes in the exchange between clinical settings.

Please share with us in the comments: 

What do you think?

Is a standardized language in nursing and/or the medical setting important?

Are you familiar with either of these terminology systems?

Do you know of any other systems?




References

Agrawal, A., He, Z., Perl, Y., Wei, D., Halper, M., Elhanan, G., & Chen, Y. (2013). The readiness of SNOMED problem list concepts for meaningful use of electronic health records. Artificial intelligence in medicine, 58(2), 73-80.

Matney, S. A., Dolin, G., Buhl, L., & Sheide, A. (2016). Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care Plan. Computers, informatics, nursing: CIN.

Warren, J. J., Matney, S. A., Foster, E. D., Auld, V. A., & Roy, S. L. (2015). Toward Interoperability: A New Resource to Support Nursing Terminology Standards. Computers Informatics Nursing, 33(12), 515-519.