Assignment Task:
Nursing languages attempt to capture everything a nurse does in order to represent the care given and then link nursing interventions to patient outcomes.
Part 1: Think about your last clinical experience. Take one patient encounter where you provided care and try to capture what you did for the patient. This might be an intervention (turning the patient) or just talking to the patient. Take this encounter apart to examine every step you took, from looking at the patient (a form of assessment) to placing the call light within reach. I want you to be specific.
Part 2: What were the desired outcomes for each of your interventions?
Part 3: How do you know the interventions had the desired effect? Think about outcomes.
Relate all of this back to having a nursing language in place through computerized documentation.
- How does having a standardized nursing language in the computerized charting help support high quality, safe patient care?
- How does having a standardized nursing language make your interventions and the patient's outcome from the care searchable in the documentation?
- Why is this important?