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Implementation of standardized nomenclature in the electronic medical record

Joan Klehr¹, Jennifer Hafner, Leah Mylrea Spelz

¹New Beginnings Birthing Center, of Aspirus Wausau Hospital, Wausau, Wisconsin, USA.

International Journal of Nursing Terminologies and Classifications : the Official Journal of NANDA International

|November 4, 2009

Abstract

Purpose:

To describe a customized electronic medical record documentation system which provides an electronic health record, Epic, which was implemented in December 2006 using standardized taxonomies for nursing documentation.

Data Sources:

Descriptive data is provided regarding the development, implementation, and evaluation processes for the electronic medical record system. Nurses used standardized nursing nomenclature including NANDA-I diagnoses, Nursing Interventions Classification, and Nursing Outcomes Classification in a measurable and user-friendly format using the care plan activity.

Conclusions And Implications:

Key factors in the success of the project included close collaboration among staff nurses and information technology staff, ongoing support and encouragement from the vice president/chief nursing officer, the ready availability of expert resources, and nursing ownership of the project. Use of this evidence-based documentation enhanced institutional leadership in clinical documentation.

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