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

Area of Science:

• Nursing Informatics
• Health Information Management

Background:

• Implementing standardized electronic nursing records presents challenges.
• Integrating international nursing terminologies into local practice requires adaptation.

Purpose of the Study:

• To describe the development and use of a nomenclature-driven electronic nursing record.
• To explore the social and behavioral challenges of using standardized nursing terminologies.
• To present strategies for improving the adoption of electronic nursing records.

Main Methods:

• Development of a nomenclature-driven electronic nursing record system.
• Translation and adaptation of international nursing nomenclatures (e.g., NANDA) to French and local practice.
• Implementation across diverse clinical settings within a university hospital network.

Main Results:

• The electronic nursing record system is utilized in nineteen wards across five hospital campuses.
• The system covers a wide spectrum of care, including adult, pediatric, surgical, medical, psychiatric, and rehabilitation services.
• Social and behavioral challenges associated with nomenclature use were identified and addressed.

Conclusions:

• Standardized nursing terminologies can be successfully integrated into electronic health records.
• Addressing user adoption challenges is crucial for the effective implementation of nursing informatics solutions.
• Adapting terminologies to local practice enhances the utility of electronic nursing documentation.