As a result of the fragmented nature of the health care system, professionals in various specialty areas of medicine have developed their own unique sets of terminology to communicate within that specialty. In the past, limited attention has been given to codifying practices in order for them to be understood and utilized across disciplines or through different information technology systems. The implementation of a federally mandated electronic medical records system, therefore, poses a challenge to nursing professionals and others who must be prepared to utilize standardized codes for the new system. Why are coding standards important for promoting consistent, high-quality care? According to Rutherford (2008, para. 15), “Improved communication with other nurses, health care professionals, and administrators of the institution in which nurses work is a key benefit of using a standardized nursing language.” In this Discussion you consider the reasoning behind and the value of standardized codification. an explanation of why nurses need to document care using standardized nursing languages and whether this standardization can be limited to specialty areas or if it should be across all nursing practice. Support your response using specific examples from your own specialty or area of expertise and using at least one additional resource from the Walden Library.

The fragmented nature of the health care system has led to the development of unique sets of terminology within various specialty areas of medicine. This lack of standardization poses challenges when it comes to communication and interoperability between different disciplines and information technology systems, especially with the implementation of a federally mandated electronic medical records system. Nursing professionals in particular must be prepared to utilize standardized codes in order to promote consistent and high-quality care.

One of the key benefits of using standardized coding in nursing is improved communication. Rutherford (2008) explains that standardized nursing languages enable better communication between nurses, other health care professionals, and administrators. By using a common language, nurses can effectively communicate the care they provide to other members of the health care team, as well as to administrators who need comprehensive data for decision-making. This improved communication can lead to more coordinated and efficient care delivery, enhancing patient outcomes.

Moreover, standardized coding promotes consistency in care delivery. By using standardized nursing languages, nurses can document and communicate essential nursing interventions and outcomes, regardless of the specialty area. This consistency ensures that every patient receives the same level of care, regardless of the setting or health care provider. For example, a patient admitted to an emergency department will receive consistent care if the nursing interventions and outcomes are documented using standardized coding, even if different nursing professionals are involved in their care.

Standardization also facilitates research and evidence-based practice in nursing. When nursing care is documented using standardized coding, it becomes easier to collect and analyze data for research purposes. Researchers can compare and aggregate data from different settings and specialties, leading to a deeper understanding of the effectiveness of specific interventions and the impact on patient outcomes. This knowledge can then be used to inform evidence-based practice and improve patient care across all nursing specialties.

While the need for standardized coding is clear, the question of whether it should be limited to specialty areas or applied across all nursing practice remains. While specialization in nursing has led to the development of specialty-specific languages and terminologies, there is still a need for a common language that can be understood and utilized by all nursing professionals. Standardized coding should, therefore, be implemented across all nursing practice to ensure consistency and interoperability.

For instance, in my area of expertise as a pediatric nurse, there are specialty-specific nursing languages and terminologies that are used to document and communicate care specific to pediatric patients. However, there is also a need for a common language that allows for effective communication and collaboration with nurses in other specialties who may be involved in the care of pediatric patients. Standardized coding ensures that communication and documentation are seamless between different disciplines, facilitating coordinated care and improving patient outcomes.

In conclusion, coding standards are crucial in promoting consistent and high-quality care in the fragmented health care system. Standardized coding enables improved communication, consistency in care delivery, and facilitates research and evidence-based practice. While there are specialty-specific nursing languages, there is a need for a common language that can be understood and utilized by all nursing professionals. Standardized coding should, therefore, be implemented across all nursing practice to ensure effective communication and collaboration, ultimately leading to better patient outcomes.