A controlled nursing vocabulary for indexing and information retrieval

Eila Pekkala1, Kaija Saranto, Marianne Tallberg

  • 1Finnish Nurses Association, Helsinki, Finland. pekkala@unlink.org

Related Concept Videos

Nursing Clinical Information System01:27

Nursing Clinical Information System

Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
Nursing Interventions II: Selecting and Classifying the Nursing Interventions01:29

Nursing Interventions II: Selecting and Classifying the Nursing Interventions

Creating and executing a nursing diagnosis helps nurses plan care and guide patient, family, and community interventions. They are developed based on a patient's physical evaluation and support measuring the outcomes. It is not recommended to select random interventions throughout the planning process. Instead, consider the following six essential factors when choosing interventions:
Nursing Interventions I: Taxonomy of Nursing Interventions01:03

Nursing Interventions I: Taxonomy of Nursing Interventions

Nursing interventions are chosen as part of the planning process to achieve patient outcomes. Once nursing diagnoses are determined, the goals and outcomes are specified, then the nursing interventions are selected and individualized according to the patient's situation.
A nursing intervention is a treatment or action based on scientific concepts and knowledge from the nursing, behavioral, and physical sciences. Identifying and prioritizing nursing interventions based on the desired outcome is...
Retrieval01:12

Retrieval

Retrieval is the process of getting information out of memory storage and back into conscious awareness. This ability is essential for daily tasks like brushing hair and teeth, driving to work, and performing job duties. Retrieval occurs in three ways: recall, recognition, and relearning.
Recall involves accessing information without cues, such as during an essay test, where individuals must retrieve facts and concepts from memory unaided. Another example is remembering the name of a colleague...
Formats for Nursing Documentation01:28

Formats for Nursing Documentation

Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
Types of Records I: Unit and Nurses Records01:27

Types of Records I: Unit and Nurses Records

Unit records in healthcare settings document the patient's treatment history, including interventions, medications, diagnostic and laboratory results, progress notes, personal care needs, vital signs, and other medical information. They are crucial for managing patient care, aiding healthcare professionals in providing quality treatment and informed decision-making.
Unit records can be divided into two main types: administrative records and clinical records.
Administrative records in...