Standardized Coding Systems and Nursing

Standardized Coding Systems and Nursing Informatics

As the pace of technological progression increases at a seemingly exponential rate, with the introduction of computer mainframes in the 1980's having paved the way for cloud-based data storage and retrieval today, the field of nursing informatics has emerged in response to the flood of medication guidelines, patient histories, and diagnostic codes that a nurse must decipher during the course of their duties. A significant transformation is currently occurring within hospitals, community clinics, and pharmacies throughout the nation, as the healthcare delivery model shifts from traditional paper filing systems and handwritten medical charts to the implementation of the electronic health record (EHR), using electronic documentation (ED) to record patient interactions. In an article published in 2008 by the Online Journal of Issues in Nursing, Marjorie a. Rutherford applies her expertise with Nursing Intervention Classification (NIC) systems and the Nursing Outcome Classification (NOC) system to examine both the need for a standardized nursing language, and the ramifications that various coding and classification systems can have on the effectiveness of nursing practice. According to the central premise of Rutherford's work, "it is impossible for medicine, nursing, or any health care-related discipline to implement the use of ED without having a standardized language or vocabulary to describe key components of the care process" (2008), and by examining the systemic structure of various nursing languages in use today, an accurate measurement of their relative efficacy can be obtained.

The use of standardized language to document care has been recognized by physicians since 1893, when the system that would eventually become the International Classification of Diseases (ICD-10) today was first instituted. While the benefits of a universal healthcare language, through which medical diagnoses and treatments can be communicated and comprehended across national borders, have been clearly established, it was not until 1973 that a standardized nursing language was first developed. Since that time several proposed coding systems for nurses have been proposed, including the Nursing Minimum Data Set (NMDS) in 1988, the Clinical Care Classification (CCC) in 1991, the Nursing Intervention Classification (NIC) in 1992, and the Nursing Outcomes Classification system (NOC) in 1997 (Rutherford, 2008). Each standardized nursing language is designed for use in a number of clinical settings, including home care, ambulatory care, and inpatient treatment, with certain languages providing decided advantages within particular circumstances. Although it is true that "improved communication with other nurses, health care professionals, and administrators of the institutions in which nurses work is a key benefit of using a standardized nursing language" (Rutherford, 2008), the proliferation of several nursing languages throughout the years has inevitably resulted in discrepancies, wherein the personal preferences of nurses, the policy of a hospital's corporate ownership, or other factors determine when, where, and why a specific language is used.