Implementing the Nursing Outcomes Classification in a clinical information system in a tertiary care setting

Area of Science:

• Nursing Informatics
• Health Information Management

Background:

• Tertiary care centers aim to integrate the Nursing Minimum Data Set into electronic medical records (EMR).
• The Nursing-Sensitive Outcomes Classification (NOC) is a key component for standardizing nursing data.
• Clinical information systems are increasingly utilized in patient care units.

Purpose of the Study:

• To describe the implementation and evaluation of the NOC within a tertiary care setting.
• To assess the utility and comprehensiveness of the NOC when integrated with an EMR and patient care guidelines.

Main Methods:

• Implementation of the NOC in selected patient care units.
• Evaluation of NOC utilization through frequency of use.
• Assessment of staff feedback regarding the NOC.
• Identification of any necessary additions to the NOC classification.

Main Results:

• The NOC was frequently used by nursing staff.
• Staff provided positive feedback on the NOC's utility.
• Minimal additions were identified as necessary for the NOC classification.
• The NOC was deemed useful and comprehensive in the EMR context.

Conclusions:

• The implementation of the NOC is feasible and beneficial in a tertiary care setting.
• The NOC effectively contributes to the Nursing Minimum Data Set within the EMR.
• Further refinement of the NOC may enhance its integration and application.