Nursing care nomenclatures: real implementation in the computerized patient care record

We report our experience in the conception and the use of a detailed nursing care documentation electronic record. This nursing care record is completely nomenclature driven, including the user-interface. International nomenclatures or classifications such as NANDA are used. They have been translated to French and their language adopted to the local practice habits. This nursing CPR is used in nineteen wards in the five campuses of the University Hospitals of Geneva, covering a broad range of nursing care types, such as acute adult and paediatric care, surgery, general internal medicine, geriatrics, in- and outpatient psychiatry and long-term rehabilitation. This paper focuses on the problematic of the use of nomenclatures and classification in a nursing daily practice, particularly the social and behavioural challenges that had to be faced. The rationale behind the use of these nomenclatures is presented. We present some of the techniques that have been used to make a nomenclature-driven nursing CPR more attractive for nurses.