The Use of Standardized Nursing Language by Physical Therapy,Occupational Therapy,and Speech Pathology in Acute Care

Abstract

BACKGROUND

The use of standardized language has expanded beyond the realm of nursing and has encouraged the development of an interdisciplinary approach to quality health care. St. Joseph's Immanuel–Mayo Health System in Minnesota was moving toward a totally integrated patient record using standardized nursing languages. Rehabilitation services were asked to review the languages for applicability to the patient care provided by the professionals in the department.

MAIN CONTENT POINTS

Standardized languages were unknown concepts to the professionals within physical, occupational, and speech therapy. Issues encountered by rehabilitation services when implementing NANDA, NIC, and NOC languages were (a) this was a new way of thinking about interdisciplinary care; (b) the languages were developed by nursing, so why would rehabilitation services benefit from using them; (c) NIC and NOC did not fully capture these specialized practices; and (d) the lack of understanding of the languages and the education required to use them.

The first step in being able to implement the use of standardized nursing language for the patients receiving rehabilitation services was for staff to understand the goal of interdisciplinary documentation to enhance communication among disciplines, that there were no standardized languages available specific to rehabilitation services, and that this was a mechanism to increase knowledge and self-awareness of each profession's role in patient care.

Educational efforts were undertaken to assist the staff in understanding the languages. NIC and NOC were reviewed for appropriateness for documentation of the services provided. Some new interventions and outcomes needed to be developed in order for the speech, physical, and occupational therapists to fully capture these specialized services. Computerized documentation was not new to the staff, but this opportunity was taken to enhance more fully the documentation process by developing an evaluation and discharge summary for each specialty.

Opportunities provided with computerization and standardized nursing languages were more efficient documentation (decreased double documentation), increased team work and clarity and improved communication among team members, the ability to think about individualization of the plan of care in a new way, and the ability to retrieve data regarding the patient care provided.

CONCLUSIONS

With change a constant in health care and the use of new technology, it is imperative to provide effective and consistent care to patients in need. The use of standardized language in an acute care setting has increased both knowledge and self-awareness of each professional's role with patient care. Communication and the networking of critical information between the patient care team and the patient/family has been enhanced by the use of the NANDA/NIC/NOC systems, thanks to the effective yet efficient form of documentation. Improved communication of transfer information on discharge to nursing homes, home health care, and other healthcare facilities has resulted. Future plans include using research methods to study the effectiveness of interventions on patient outcomes.