Nursing knowledge captured in electronic health records.

Area of Science:

• Nursing Informatics
• Health Information Management

Background:

• Electronic health records (EHR) offer a platform to document nursing clinical judgment and enhance the visibility of nursing care.
• Standardized nursing terminologies, including North American Nursing Diagnosis Association-International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC), are essential for consistent and measurable nursing practice.

Purpose of the Study:

• To evaluate the extent of nursing assessment data within the EHR.
• To determine the linkage between nursing assessment data and standardized terminologies (NANDA-I, NIC, NOC).

Main Methods:

• A retrospective descriptive review of EHR documentation for 10 cardiac surgery patients.
• Utilized Gordon's Functional Health Pattern (FHP) Framework for organizing health history data.
• Employed a Delphi consensus-building process with expert reviewers to identify documentation supports and barriers.

Main Results:

• Nursing assessment data collection included 75 fields, with 65 for health history and 30 for physical findings; however, defining characteristics or etiologies were not linked to diagnostic labels.
• Care plans contained nursing diagnoses, goals, and interventions, but lacked clear alignment with assessment data and standardized terminologies.
• Progress notes documented clinical events but were not focused on nursing problems or diagnoses.
• Experts identified supports and challenges impacting the documentation of nursing care using FHPs and standardized language in the EHR.

Conclusions:

• The EHR has the potential to showcase nursing contributions, but current documentation practices present challenges in capturing nurse-focused data.
• Accurate capture of nursing data in EHRs is vital for resource allocation, quality care delivery, and advancing nursing knowledge through standardized outcomes.