How nursing interventions classification fits in the patient information system Patient Core Data Set

Area of Science:

• Health Informatics
• Nursing Science

Background:

• The Patient Core Data Set (PCDS) is a comprehensive patient health record.
• PCDS includes domains for patient identification, service elements, and health elements.
• The health elements domain captures procedures and treatments rendered.

Purpose of the Study:

• To evaluate the suitability of the Nursing Interventions Classification (NIC) for the PCDS.
• To highlight the necessity of standardized language in nursing documentation.

Main Methods:

• The study describes the structure of the PCDS, focusing on the 'procedures/treatment rendered' section.
• It details the components of NIC, including intervention labels, definitions, and activities.
• The conceptual level and task-oriented nature of NIC are discussed.

Main Results:

• The PCDS has a 'nursing intervention' subcategory within its health elements.
• NIC interventions are conceptual and composed of discrete, task-level activities (20-30 per intervention).
• NIC's structure and detail are identified as a strong match for PCDS requirements.

Conclusions:

• A standardized language is essential for effective nursing communication and documentation.
• The Nursing Interventions Classification (NIC) is well-suited for integration into the Patient Core Data Set (PCDS).
• Implementing NIC in PCDS can enhance the recording of nursing care.