Learning Objective #1: Relate standardized languages to performance improvement and patient safety

Learning Objective #2: Discuss various applications of a standardized nursing language to clinical documents

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Standardized nursing languages were originally developed to facilitate electronic documentation of care in the health record. The assets of a recognized language, codification, definition, and consistency, are valuable management tools when integrated into competency assessments, project improvements, policies and procedures, clinical pathways/care plans, job descriptions, or any other departmental document. Retrospective review of the electronic health record can validate clinician competency if codified nursing interventions from the language serve as measurable criteria for each competency. Nursing interventions linked to patient outcomes and required by institutional policy/procedure can be verified as documented in the electronic health record. Project improvements can be triggered when nursing interventions essential to patient safety are trended and compared to internal or external benchmarks. Orienting new nurses to expected patient practices that contain the same language regardless of the setting, regional location, or subspecialty, is a cost efficient, logical method of staff nurse education at the unit level. Using universally defined nursing terms in departmental documents that are consistent with EHR documentation improves patient safety and the quality of delivered care.