Why the nursing profession needs to embrace information standards
Many years ago, when I worked on wards, I was responsible for recording a patient's information at the end of a night shift. If the night had been uneventful, we would write 'slept well' in the patient's record, usually in a Kardex system on paper. Most of the information I recorded will have never have been looked at again, disappearing into the depths of paper records as time passed. In the brave new digital world, data in record systems doesn't decay in the same way, and is used for research purposes as well as to improve patient care. The emergence of big data, machine learning and artificial intelligence (AI) means that everything we record has the potential to be re-used.
Change is definitely upon us, and that means it's time for the nursing profession to get serious about data quality. With access to high-quality, standardised information, we will be able to make better decisions about a person's care and improve our clinical processes. But ensuring that the data we enter is accurate and timely is only part of the story. As the Professionals Record Standards Body works to develop standards for record sharing, nursing professionals must get serious about implementation and adoption of standards as the norm. Through standardised terminology, we can record and access a wide range of information essential to patient care. For example, we need standards for how we record a patient's weight across systems, as it could be used to calculate a dose of a medication. We need to ensure we consistently record nursing observations such as pressure ulcers, so we can measure improvement and compare across systems/organisations. All of these care requirements must be recorded in a standardised way so that when we communicate across organisational boundaries, they don't lose meaning.
The PRSB's information standards can apply across health and care, helping us to measure nursing outcomes, compare performance, share information and, for the future, provide data that will support accurate AI. But for standardisation to be truly effective, we need to do this for the whole profession. If we continue to believe that each organisation is a digital island, with its on special requirements and its own way of recording nursing practice, we will fail to capitalise on the potential data offers nursing. Exactly how many versions of a fluid balance chart do we need to create?
Words like 'terminology' and 'classification' system can seem daunting, and often get dismissed as compliance issues. Moving forward we need the nursing community to fully embrace what standardisation will mean for the profession and patients: safer and better care throughout the system.
Find out more about standards at www.theprsb.org or if you are interested in supporting the PRSB's work, please contact email@example.com.