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Article
Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care
Online Journal of Nursing Informatics
  • Cynthia B. Lundberg
  • Judith J. Warren
  • Jane Brokel, University of Iowa
  • Gloria M. Bulechek
  • Howard K. Butcher, University of Iowa
  • Joanne McCloskey Dochterman
  • Marion Johnson
  • Meridean Maas, University of Iowa
  • Karen S. Martin
  • Sue Moorhead, University of Iowa
  • Christine Spisla
  • Elizabeth A. Swanson, University of Iowa
  • Sharon Giarrizzo-Wilson
Document Type
Article
Peer Reviewed
1
Publication Date
6-1-2008
NLM Title Abbreviation
Online J Nurs Inform
Total Pages
20
Abstract
Using standardized terminology within electronic health records is critical for nurses to communicate their impact on patient care to the multidisciplinary team. The universal requirement for quality patient care, internal control, efficiency and cost containment, has made it imperative to express nursing knowledge in a meaningful way that can be shared across disciplines and care settings. The documentation of nursing care, using an electronic health record, demonstrates the impact of nursing care on patient care and validates the significance of nursing practice. As key stakeholders of the American Nursing Association recognized terminologies, NANDA, NIC, NOC, Omaha System, PNDS, and SNOMED CT describe their respective classification systems to assist administrators, nursing executives, informatics nurses, nurse managers and staff nurses to make decisions concerning the selection of a nursing terminology or a combination of nursing terminologies that best meets their organizational needs.
Keywords
  • Charting,
  • Classification,
  • Computerized Patient Record,
  • Nursing Care,
  • Nursing Informatics,
  • American Nurses Association,
  • Information Resources,
  • Iowa Nursing Interventions Classification,
  • Iowa Nursing Outcomes Classification,
  • NANDA International,
  • Omaha System,
  • Perioperative Nursing,
  • Snomed,
  • World Wide Web
Published Article/Book Citation

Online Journal of Nursing Informatics, 12:2 (2008) pp.19p-19p.

Rights
Copyright © Healthcare Information and Management Systems Society, 2008. Posted by permission.
Disciplines
Citation Information
Cynthia B. Lundberg, Judith J. Warren, Jane Brokel, Gloria M. Bulechek, et al.. "Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care" Online Journal of Nursing Informatics Vol. 12 Iss. 2 (2008) ISSN: 1089-9758
Available at: http://works.bepress.com/jane_brokel/32/