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[Development of a computerized system using standard nursing language for creation of a nursing minimum data set]
Fabio D'Agostino1, Ercole Vellone, Francesco Tontini
1Dottorando di Ricerca in Scienze Infermieristiche, Università di Roma Tor Vergata. dagostinofabi@hotmail.it
Professioni Infermieristiche
|July 17, 2012
Summary
Developing a structured nursing documentation system is crucial for assessing population health and care. This project aims to create a computer system using standard nursing terms to improve data collection and decision-making.
Area of Science:
- Nursing Informatics
- Health Information Management
- Public Health Data Analysis
Context:
- Incomplete nursing data hinders population health assessment in Italy and globally.
- Lack of structured nursing documentation limits evaluation of care, costs, and health needs.
- Standardized nursing language is essential for comprehensive data collection.
Purpose:
- To develop a computer system utilizing standard nursing terminology.
- To create dedicated software for aiding nursing-related decision-making and documentation.
- To establish a framework for a Nursing Minimum Data Set (NMDS).
Summary:
- The project focuses on creating a computer system with standard nursing terms and dedicated software.
- This system aims to facilitate the evaluation of nursing activities, associated costs, and patient health outcomes.
- Implementation requires adequate training and involvement of nursing staff for successful data monitoring.
Impact:
- Improved monitoring of nursing activities and costs.
- Enhanced ability to assess the impact of nursing care on patient health outcomes.
- Foundation for a standardized Nursing Minimum Data Set (NMDS) to inform health policy and resource allocation.
Related Concept Videos
01:10Documentation of Nursing Diagnosis
The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
01:27Nursing 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:
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:
01:24Data Reporting and Recording
Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
01:29Data Collection II
The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and family,...
01:26Formulating and Validating Nursing Diagnosis I
A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent nursing interventions. The standardized terminologies of a nursing diagnosis help nurses identify and treat patients' problems. Every electronic health record that uses nursing diagnosis must employ standard diagnostic terminology. Developing an efficient, individualized care plan begins with accurate nursing diagnoses.
There are thirteen domains for...
There are thirteen domains for...
01:28Formats 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...
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...