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Related Concept Videos

Nursing Clinical Information System01:27

Nursing Clinical Information System

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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:
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Nursing Process for Patient and Caregiver Teaching I: Assessment and Diagnosis01:24

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The nursing process provides a clinical decision-making framework for patients and families to establish and implement a personalized care plan. Since part of the nurse's duties is to teach patients, the steps of the nursing process are the most effective way to approach instruction. The nursing process and the teaching-learning process are inextricably linked.
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Formulating and Validating Nursing Diagnosis I01:26

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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.
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Nursing Interventions I: Taxonomy of Nursing Interventions01:03

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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.
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Nursing Interventions II: Selecting and Classifying the Nursing Interventions01:29

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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:
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Documentation of Nursing Diagnosis01:10

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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.
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Using Learning Outcome Measures to assess Doctoral Nursing Education
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Information model for learning nursing terminology.

Jan Pettersen Nytun1, Mariann Fossum2

  • 1Faculty of Engineering and Science, University of Agder, 4876 Grimstad, Norway.

Studies in Health Technology and Informatics
|August 28, 2014
PubMed
Summary
This summary is machine-generated.

This study introduces an information model and application to teach nursing students the International Classification for Nursing Practice (ICNP®) for better nursing care planning and documentation.

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Area of Science:

  • Nursing Informatics
  • Health Information Management
  • Medical Terminology

Background:

  • Standardized terminologies enhance healthcare information quality and patient care.
  • The International Classification for Nursing Practice (ICNP®) is a unified nursing language system for documenting diagnoses, interventions, and outcomes.

Purpose of the Study:

  • To present an information model integrating ICNP with other ontologies.
  • To develop an application for teaching nursing students ICNP use in care planning.

Main Methods:

  • Developed an information model integrating ICNP, catalog, patient journal, and task set ontologies.
  • Created a learning application presenting patient scenarios and prompting for nursing statements (diagnoses, goals, interventions).

Main Results:

  • The application allows students to select premade ICNP-based solutions or construct statements directly from ICNP terms.
  • The model facilitates structured documentation and learning of nursing care planning.

Conclusions:

  • The developed model and application effectively teach nursing students to utilize ICNP for comprehensive nursing care planning.
  • This approach supports improved nursing documentation and information quality.