Standardized Coding Systems

Standardized Coding Systems

Standardized Coding Systems

Discussion: Standardized Coding Systems

Discussion: Standardized Coding Systems

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.

To prepare FOR Discussion: Standardized Coding Systems:
Review the information in Nursing Informatics: Scope and Standards of Practice. Determine which set of terminologies are appropriate for your specialty or area of expertise.

Reflect on the importance of continuity in terminology and coding systems.

In the article, “Standardized Nursing Language: What Does It Mean for Nursing Practice?” the author recounts a visit to a local hospital to view its implementation of a new coding system. One of the nurses commented to her, “We document our care using standardized nursing languages but we don’t fully understand why we do” (Rutherford, 2008, para. 1). Consider how you would inform this nurse (and others like her) of the importance of standardized nursing terminologies.

Reflect on the value of using a standard language in nursing practice. Consider if standardization can be limited to a specialty area or if one standard language is needed across all nursing practice. Then, identify examples of standardization in your own specialty or area of expertise. Conduct additional research using the Walden Library that supports your thoughts on standardization of nursing terminology.

By Day 3 OF Discussion: Standardized Coding Systems
Post 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.

Read a selection of your colleagues’ responses.

By Day 6 OF Discussion: Standardized Coding Systems
Respond to at least two of your colleagues on two different days using one or more of the following approaches:

Ask a probing question, substantiated with additional background information, evidence or research.
Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.
NURS 6051 Week 6 Assignment: Application: Adoption of New Technology Systems
As a nurse, you can have a great impact on the success or failure of the adoption of EHRs. It is important for nurses to understand their role as change agents and the ways they can influence others when addressing the challenges of changing to a drastically different way of doing things.

Everett Rogers, a pioneer in the field of the diffusion of innovations, identified five qualities that determine individual attitudes towards adopting new technology (2003). He theorized that individuals are concerned with:

Relative advantage: The individual adopting the new innovation must see how it will be an improvement over the old way of doing things.

Compatibility with existing values and practices: The adopter must understand how the new innovation aligns with current practices.

Simplicity: The adopter must believe he or she can easily master the new technology; the more difficult learning the new system appears, the greater the resistance that will occur.

Trialability: The adopter should have the opportunity to “play around’ with the new technology and explore its capabilities.

Observable results: The adopter must have evidence that the proposed innovation has been successful in other situations.

Note: You are not required to purchase Rogers’ book or pursue further information regarding his list of five qualities. The information provided here is sufficient to complete this Assignment. The full reference for Rogers’ work is provided below the due date on this page.

For this Assignment, you assume the role of a nurse facilitator in a small hospital in upstate New York. You have been part of a team preparing for the implementation of a new electronic health records system. Decisions as to the program that will be used have been finalized, and you are now tasked with preparing the nurses for the new system. There has been an undercurrent of resistance expressed by nurses, and you must respond to their concerns. You have a meeting scheduled with the nurses 1 week prior to the training on the new EHR system. Consider how you can use the five qualities outlined by Rogers (2003) to assist in preparing the nurses for the upcoming implementation.

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To prepare

Review the Learning Resources this week about successful implementations of EHRs.

Consider how you would present the new EHR system to the nurses to win their approval.

Discussion Standardized Coding Systems
Discussion Standardized Coding Systems

Reflect on the five qualities outlined by Rogers. How would addressing each of those areas improve the likelihood of success?

By Day 7 of Week 6

Write a 3- to 5-page paper which includes the following:

Using Rogers’ (2003) theory as a foundation, outline how you would approach the meeting with the nurses. Be specific as to the types of information or activities you could provide to address each area and include how you would respond to resistance.

Analyze the role of nurses as change agents in facilitating the adoption of new technology.

Medical Coding Assignment
1) Assign CPT code(s) and appropriate modifiers to each statement.

The physician performed a complex repair during resection of the diaphragm and closed the residual defect with synthetic graft material.

2) Mediastinotomy to remove foreign body using transthoracic approach, including median sternotomy.

3) Patient underwent repair, laceration of diaphragm.

4) Physician inserted a mediastinoscope through an incision in the sternal notch and performed a mediastinal lymph node biopsy.

5) Physician repaired an acute traumatic diaphragmatic hernia.

Patient underwent alveoloplasty to remove sharp areas or undercuts of alveolar bone, one quadrant.

Surgeon used a scalpel to slice off a cancerous portion of the vermillion border of the patient’s lip: mucosal advancement was performed after excision.

Surgeon made an incision through submucosal tissue and removed a lesion in the vestibule of the mouth. Wound repair was not required.

Patient underwent simple incision of the lingual frenum to free the tongue.

Patient underwent incision in the parotid gland to remove calcified stone.

Surgeon repaired a tear at the pharyngeal esophageal junction.

Physician drained and abscess near the tonsil.

Surgeon removed an 8 year old patient’s tonsils and adenoids.

Physician controlled secondary oropharyngeal hemorrhaging, status post tonsillectomy, by using cellulose sponges that expanded when placed in the tonsillar cavity.

Physician performed a tonsillectomy on a 12 year old male patient.

Physician inserted a flexible esophagoscope into the esophagus and destroyed a lesion, using snare technique.

Surgeon made an incision in the left posterior chest wall into the esophagus to remove a foreign body from the esophagus.

Physician inserted a balloon endoscopically for tamponade of bleeding esophageal varices.

Dr. Smith performed a partial cervical esophagectomy while Dr. Jones performed a jejunum transfer with microvascular anastomosis.

The physyician passed an endoscope through the patient’s mouth and visualized the entire esophagus, stomach, duodenum, and jejunum. One lesion was removed using biopsy forceps. Another was remove using snare.

Patient underwent incision of the pyloric muscle.

The physician performed an open revision of a previously performed gastric restrictive procedure and reversed the previously partitioned stomach to restore normal gastrointestinal continuity.

Using fluoroscopic guidance, the physician repositioned a gastric feeding tube through the duodenum.

The physician performed a laparoscopic surgical gastric restrictive procedure with gastric bypass and roux-en-Y gastroenterostomy.

The physician percutaneously place a gastrostomy tube into the stomach under fluoroscopic guidance including contrast injection(s), image documentation.

NURS 6051 Week 4 Assignment: Using the Data/Information/Knowledge/Wisdom Continuum
Have you ever gone online to search for a journal article on a specific topic? It is amazing to see the large number of journals that are available in the health care field. When you view the library in its entirety, you are viewing untapped data. Until you actually research for your particular topic, there is little structure. Once you have narrowed it down, you have information and once you apply the information, you have knowledge. Eventually, after thoughtful research and diligent practice, you reach the level of wisdom—knowledge applied in meaningful ways.

Are there areas in your practice that you believe should be more fully explored? The central aims of nursing informatics are to manage and communicate data, information, knowledge, and wisdom. This continuum represents the overarching structure of nursing informatics. In this Assignment, you develop a research question relevant to your practice area and relate how you would work through the progression from data to information, knowledge, and wisdom.

To prepare:

Review the information in Figure 6–2 in Nursing Informatics and the Foundation of Knowledge.

Develop a clinical question related to your area of practice that you would like to explore.

Consider what you currently know about this topic. What additional information would you need to answer the question?

Using the continuum of data, information, knowledge, and wisdom, determine how you would go about researching your question.

Explore the available databases in the Walden Library. Identify which of these databases you would use to find the information or data you need.

Once you have identified useful databases, how would you go about finding the most relevant articles and information?

Consider how you would extract the relevant information from the articles.

How would you take the information and organize it in a way that was useful? How could you take the step from simply having useful knowledge to gaining wisdom?

By Day 7 of Week 4

Write a 3- to 4-page paper that addresses the following:

Summarize the question you developed, and then relate how you would work through the four steps of the data, information, knowledge, wisdom continuum. Be specific.

Identify the databases and search words you would use.

Relate how you would take the information gleaned and turn it into useable knowledge.

Can informatics be used to gain wisdom? Describe how you would progress from simply having useful knowledge to the wisdom to make decisions about the information you have found during your database search.

Your paper must also include a title page, an introduction, a summary, and a reference page