NOW FOR AN ORIGINAL PAPER ASSIGNMENT:Assignment: School of Nursing Website

Keenan (1999) observed that throughout history nurses have documented nursing care using individual and unit-specific methods; consequently, there is a wide range of terminology to describe the same care. Although there are other more complex explanations, Keenan supplies a straightforward definition of standardized nursing language as a “common language, readily understood by all nurses, to describe care” (Keenan, p. 12). The Association of Perioperative Registered Nurses (AORN) (n.d.) adds a dimension by explaining that a standardized language “provides nurses with a common means of communication.” Both convey the idea that nurses need to agree upon a common terminology to describe assessments, interventions, and outcomes related to the documentation of nursing care. In this way, nurses from different units, hospitals, geographic areas, or countries will be able to use commonly understood terminology to identify the specific problem or intervention implied and the outcome observed. Standardizing the language of care (developing a taxonomy) with commonly accepted definitions of terms allows a discipline to use an electronic documentation system.

Consider, for example, documentation related to vaginal bleeding for a postpartum, obstetrical patient. Most nurses document the amount as small, moderate, or large. But exactly how much is small, moderate, or large? Is small considered an area the size of a fifty-cent piece on the pad? Or is it an area the size of a grapefruit? Patients benefit when nurses are precise in the definition and communication of their assessments which dictate the type and amount of nursing care necessary to effectively treat the patient.

The Duke University School of Nursing website < www.nursing.duke.edu> has a list of guidelines for the nurse to use for evaluation of a standardized nursing language. The language should facilitate communication among nurses, be complete and concise, facilitate comparisons across settings and locales, support the visibility of nursing, and evaluate the effectiveness of nursing care through the measurement of nursing outcomes. In addition to these guidelines the language should describe nursing outcomes by use of a computer-compatible coding system so a comprehensive analysis of the data can be accomplished.