The use of nursing terminology in electronic documentation

The purpose of this study is to describe the use of nursing terminology in nursing documentation in the neurological care setting. The use of standardized terminology in nursing documentation allows the visualization of nursing practice and makes it quantifiable. Once collected, data can also be reused for administrative purposes. In Finland the Nursing Minimum Data Set (NMDS) is part of the core data set of patient electronic health records. The Nursing Minimum Data Set has been complied using the Finnish Classification of Nursing Interventions (FiCNI) and Finnish Classification of Nursing Diagnoses (FiCND), both based on the Clinical Care Classification. Standardized terminology was introduced in nursing documentation in 2004. The data form part of a wider set of electronic health record data (2003-2006). The data consist of 40 neurological nursing care plans. The data were analysed using statistical methods and content analysis. Nursing terminology had been widely used in nursing documentation. However, there remains a clear need for both training in and further validation of the terminology currently used.