Oncology nurses are experts in conducting comprehensive assessments of symptoms and patient responses to treatments, but documentation in electronic health records frequently results in data that cannot be readily shared or compared because of a lack of standardization of the terms. Standardized nursing terminology can enhance communication among nurses and between nurses and other members of the healthcare team. It can improve care coordination and may enable nurses to capture and make visible the unique, holistic perspective that they provide to patient care. Standardization also is important for large-scale data aggregation, which will enable healthcare teams to learn about particular subsets of patients so that care can be tailored to individual characteristics and responses.
At a Glance
- In 2015, the American Nurses Association (ANA) published a position statement that reaffirmed support for the use of ANA-recognized terminologies in an effort to facilitate interoperability of the data collected by nurses.
- Within individual healthcare organizations, immediate benefits of standardization include improving communication, capturing the value of what nurses really do, and improving patient care.
- Nurses need to understand the importance of standardized nursing documentation and, where necessary, gain the knowledge and skills necessary to champion the inclusion of nursing data in standardization efforts.