DOCSLIB.ORG

The Benefits of Using Standardized Nursing Terminology

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
The Benefits of Using Standardized Nursing Terminology Page 1 of 20 Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care By Cynthia B. Lundberg, R.N., BSN; SNOMED Terminology Solutions; Judith J. Warren, PhD, RN, BC, FAAN, FACMI; University of Kansas; Jane Brokel, PhD, RN, NANDA International; Gloria M. Bulechek, PhD, RN, FAAN; Nursing Interventions Classification; Howard K. Butcher, PhD, RN, APRN, BC; Nursing Interventions Classification; Joanne McCloskey Dochterman, PhD, RN, FAAN; Nursing Interventions Classification; Marion Johnson, PhD, RN; Nursing Outcomes Classification; Meridean Maas PhD, RN; Nursing Outcomes Classification; Karen S. Martin, RN, NSN, FAAN; Omaha System; Sue Moorhead PhD, RN, Nursing Outcomes Classification; Christine Spisla, RN, MSN; SNOMED Terminology Solutions; Elizabeth Swanson, PhD, RN; Nursing Outcomes Classification, Sharon Giarrizzo-Wilson, RN, BSN/MS, CNOR, Association of PeriOperative Registered Nurses Citation: Lundberg, C., Warren, J.., Brokel, J., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Johnson, M., Mass, M., Martin, K., Moorhead, S., Spisla, C., Swanson, E., & Giarrizzo-Wilson, S. (June, 2008). Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care. Online Journal of Nursing Informatics (OJNI), 12, (2). Available at http:ojni.org/12_2/lundberg.pdf Page 2 of 20 Abstract Using standardized terminology within electronic health records is critical for nurses to communicate their impact on patient care to the multidisciplinary team. The universal requirement for quality patient care, internal control, efficiency and cost containment, has made it imperative to express nursing knowledge in a meaningful way that can be shared across disciplines and care settings. The documentation of nursing care, using an electronic health record, demonstrates the impact of nursing care on patient care and validates the significance of nursing practice. As key stakeholders of the American Nursing Association recognized terminologies, NANDA, NIC, NOC, Omaha System, PNDS, and SNOMED CT describe their respective classification systems to assist administrators, nursing executives, informatics nurses, nurse managers and staff nurses to make decisions concerning the selection of a nursing terminology or a combination of nursing terminologies that best meets their organizational needs. Key Words: Nursing Terminology, Standardized nursing terminology, NANDA International, Nursing Intervention Classification (NIC), Nursing Outcome Classification (NOC), Omaha System, Perioperative Nursing Data Set (PNDS), and Systematized Nomenclature of Medicine (SNOMED CT) Introduction The care nurses provide to variety of care settings. Selecting the sustain life, enable recovery, appropriate nursing terminology alleviate suffering and promote implementation for use in the EHR health should be captured within the can be daunting. electronic health record (EHR). To This article will highlight share this information between selected American Nursing clinical disciplines and care settings, Association’s (ANA) recognized data needs to be recorded and stored nursing terminologies and their in a standardized form. relationships to each other. This Terminologies are one way to ensure discussion will assist in making standardization so patient care data decisions about the combination of can be stored in an unambiguous nursing terminologies that best fit way. Nursing has numerous your organization’s practice and terminologies, each developed for a requirements for the EHR. Benefits of Implementing Standardized Terminologies within Electronic Health Records Standardized nursing benefit by being able to measure terminologies provide benefits to nursing care and its impact on the patient, the organization, the patient care through queries of the nursing profession, and each patient record instead of costly country. Patients benefit from manual chart audits. This continuity of care being facilitated determination of nursing’s impact is through the use of standardized essential to validating the terminologies through improved contribution of nursing to and unambiguous communication healthcare and patient safety. between clinicians. Organizations Furthermore, the organization Page 3 of 20 benefits from the use of standard reveal the impact of nursing care terminologies by providing through electronic means (Weaver, administrators with the actual costs Warren, & Delaney, 2005). Each and benefits of nursing care. Then country benefits by having informed decisions can be made retrievable coded data that can be regarding staffing ratios. This aggregated into informative reports strategy has been useful for or data sets. These reports allow physicians using the Common countries to compare nursing’s Procedural Terminology (CPT contribution to care both nationally codes) for billing purposes and internationally using the (Giannangelo & Fenton, 2008). International Nursing Minimum Nurse educators use standardized Data Set. (Goosen, et al, 2006). terminologies in the curriculum to The standardized nursing teach nursing concepts that are terminologies, recognized by the critical in the nursing process and American Nursing Association are vital to developing new nurses (ANA), are the vehicles for the (Warren, Connors, & Weaver, aggregation of nursing data 2002). The registered nurse benefits recorded in EHRs which can be from the use of standardized used to improve quality of patient nursing terminologies to facilitate care and patient safety. critical thinking and decision Giannangelo and Fenton (2008) making at the point of care state that EHRs “must use (Dochterman, Titler, Wang, & consistent, codified terminology to Reed, 2005). The nursing eliminate ambiguity, confusion, and profession benefits from being ensure data correctness and provided a means to document, interoperability…standardized store, and retrieve evidence-based terminologies identify the discrete practice in a semantic way to structured data that allow data facilitate nursing research and capture and processing (p. 29).” American Nursing Association Recognized Terminologies The ANA Committee for vocabulary that supports nursing Nursing Practice Information and are clinically relevant for the Infrastructure (CNPII) has defined nursing domain. The terminologies specific criteria used to recognize need to possess clear and standardized terminologies. These unambiguous concepts with a criteria are foundational to the coding scheme containing one standardization of nursing unique identifier per concept. The documentation and verbal terminologies must contain communication that will lead to a documented testing of reliability, reduction in errors and an increase validity and clinical usefulness in in the quality and continuity of care practice to become recognized (American Nursing Association (American Nursing Association [ANA], 2006, 1). The ANA criteria [ANA], 2006, 1). The ANA require that terminologies possess recognized nursing terminologies Page 4 of 20 are listed in alphabetical order in Table 1. Table 1: ANA recognized terminologies ANA Recognized Terminology URL Nursing Process Date Integrated Terminologies within Terminology Recognized by Within Other the ANA Terminologies CCC http://www.sabacare.com/ Diagnoses, Clinical Care Interventions, and Classification Outcomes ICNP International http://www.icn.ch/icnp.ht Diagnoses, Classification of m Interventions, and Nursing Practice Outcomes NANDA www.nanda.org Nursing Diagnoses 1992 NLM- UMLS NANDA SNOMED CT International PNDS HL7 NIDSEC NIC www.nursing.uiowa.edu/c Interventions 1992 NLM- UMLS Nursing nc SNOMED CT Intervention HL7 Classification NIDSEC ABC Codes NOC www.nursing.uiowa.edu/c Outcomes 1998 NLM- UMLS Nursing Outcome nc Indicators SNOMED CT Classification HL7 NIDSEC Omaha System www.omahasystem.org Problem 1992 NLM- UMLS Classification Scheme SNOMED CT Intervention Scheme HL7 Problem Rating Scale NIDSEC for Outcomes LOINC ABC Codes PNDS www.aorn.org/PracticeRe Diagnoses, 1999 NLM- UMLS Perioperative sources/PNDS Interventions and SNOMED CT Nursing Data Set Outcomes HL7 SNOMED CT httpwww.cap.org/apps/ca Assessment concepts, 2002 NLM- UMLS Systematic p.portal? Diagnoses, Nomenclature of _nfpb=true&_pageLabel= Interventions, and Medicine Clinical snomed_page Outcomes Terms Page 5 of 20 Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) SNOMED CT is a concepts and relationships used comprehensive, scientifically precisely in recording and validated clinical terminology and representing clinical information infrastructure for healthcare across the scope of healthcare. containing a broad coverage of SNOMED CT is concept-based, terminology supporting healthcare meaning each concept has a distinct documentation through the definition and a unique code continuum of care. SNOMED CT identifier. SNOMED CT consists of provides a consistent way of 19 top-level hierarchies, e.g.: indexing, storing, retrieving and procedures (medical and surgical aggregating clinical data across procedures, laboratory and specialties and sites of care. The use radiology procedures, interventions, of SNOMED CT within electronic education and management health records provides interoperable procedures), clinical findings, data extraction and analysis that can (nursing diagnoses, disorders, be shared across clinicians, clinical diseases that are necessarily settings and organizations both abnormal, clinical observations and nationally and internationally.
Load more

Recommended publications
  • How to Display Your Credentials
    How to Display Your Credentials How to display your credentials Common questions and answers about displaying your credentials in the proper order why do we need a standard other certifications include non-nursing way to list credentials? certifications that recognize additional skills. One example is the EMT-Basic/EMT, awarded by the Having a standard way ensures that everyone— National Registry of Emergency Medical Technicians. including nurses, healthcare providers, consumers, third-party payers, and government officials— understands the significance and value of credentials. what credentials do i Have to use? On legal documents such as prescriptions and notes what is the preferred order of credentials? on medical records, you must use the credentials required by your state for your area of practice, for The preferred order is: example, Susan Jones, RN, or Joyce Smith, APRN. Highest earned degree In professional endeavors such as speaking, Licensure writing for publication, or providing testimony State designations or requirements before a legislative body, use all your relevant National certifications credentials. Note that journals sometimes order Awards and honors credentials differently, and it is acceptable to conform to their style. Other recognitions what if i Have More than one why is this order recommended? of the same type of credential? The education degree comes first because it is List the highest education degree first, for example, a “permanent” credential, meaning it cannot be Michael Anderson, PhD, MSN. In most cases, one taken away except under extreme circumstances. degree is enough, but if your second degree is in The next two credentials (licensure and state another relevant field, you may choose to list it.
    [Show full text]
  • MIGRATION of NURSING and MIDWIFERY WORKFORCE in the STATE of KERALA This Report Was Prepared by Researchers from Oxford Policy Management (Krishna D
    CASE STUDY | INDIA FROM BRAIN DRAIN TO BRAIN GAIN MIGRATION OF NURSING AND MIDWIFERY WORKFORCE IN THE STATE OF KERALA This report was prepared by researchers from Oxford Policy Management (Krishna D. Rao, Aarushi Bhatnagar, Radhika Arora, Swati Srivastava, Udit Ranjan), the Centre for Development Studies, Trivandrum (S. Irudaya Rajan, Sunitha Syam), the Health Systems Research India Initiative (Arun Nair, S.J. Sini Thomas), and the WHO Country Office for India (Tomas Zapata). Please address all correspondence to Krishna D. Rao ([email protected]) and Aarushi Bhatnagar ([email protected]) © WHO, all rights reserved November 2017 Contents Acknowledgements .......................................................3 6. Discussion ....................................... 29 Abbreviations ...............................................................4 6.1 Production, stock and migration of nurses ....... 29 6.1.1 Production ...................................... 29 Executive summary ........................................................5 6.1.2 Stock .............................................. 30 1. Background ........................................ 7 6.1.3 Migration ........................................ 31 6.2 Factors influencing migration patterns ............ 33 1.1 Kerala state ..................................................9 6.2.1 Endogenous push and pull factors ....... 33 1.2 Migration of health workers........................... 10 6.2.2 Exogenous push and pull factors .........34 2. Objectives .......................................
    [Show full text]
  • A Methodology for Developing a Nursing Education Minimum Dataset Aziza A
    University of South Florida Scholar Commons Graduate Theses and Dissertations Graduate School 11-10-2005 A Methodology for Developing a Nursing Education Minimum Dataset Aziza A. Rajab University of South Florida Follow this and additional works at: https://scholarcommons.usf.edu/etd Part of the American Studies Commons Scholar Commons Citation Rajab, Aziza A., "A Methodology for Developing a Nursing Education Minimum Dataset" (2005). Graduate Theses and Dissertations. https://scholarcommons.usf.edu/etd/826 This Dissertation is brought to you for free and open access by the Graduate School at Scholar Commons. It has been accepted for inclusion in Graduate Theses and Dissertations by an authorized administrator of Scholar Commons. For more information, please contact [email protected]. A Methodology for Developing a Nursing Education Minimum Dataset by Aziza A. Rajab A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy College of Nursing University of South Florida Major Professor: Mary E. Evans, Ph.D. Patricia Burns, Ph.D. Arthur Shapiro, Ph.D. Jason Beckstead, Ph.D. Date of Approval: November 10, 2005 Keywords: coding scheme, classification systems, Delphi, focus group, nursing database, nursing data element, nursing education, online survey, ontology, taxonomy, unified nursing language © Copyright 2005, Aziza A. Rajab Acknowledgments Thanks goes first to God Almighty, Allah the most merciful, compassionate, and gracious, for granting me the health and ability to conduct this study. A very special thank you goes to my advisor, chair, and Associate Dean for Research & Doctoral Study in the College of Nursing, Dr. Mary E. Evans for her guidance, supervision, and instruction throughout my doctoral studies and this research.
    [Show full text]
  • Nursing Research: Challenges
    NURSING RESEARCH: CHALLENGES AND OPPORTUNITIES PRESENTED BY OPARA HOPE CHIZOLUM AT GLOBAL RESEARCH NURSES WORKSHOP 24th and 25th May 2021 NNAMDI AZIKIWE UNIVERSITY TEACHING HOSPITAL, NNEWI OUTLINE FOR THE PRESENTATION INTRODUCTION WHAT IS NURSING RESEARCH? IMPORTANCE OF RESEARCH TO NURSING WHAT ARE THE OPPORTUNITIES? CHALLENGES FACED BY NURSE RESEARCHERS WAY FORWARD CONCLUSION INTRODUCTION Research is a way of thinking: examining critically the various aspects of your day-to-day work; understanding and formulating guiding principles that govern a procedure; and developing and, testing new theories that contribute to the advancement of your practice and profession (Odunze, 2019). It is a habit of questioning what you do, and a systematic examination of clinical observations to explain and find answers for what you perceive, with a view to instituting appropriate changes for a more effective professional service (Kumar et al, 2016) Today’s healthcare system is complex, and patients have increasingly varied needs. Developing solutions for the health issues of diverse populations requires providers with many different perspectives (National Institute of Nursing Research, 2016). Nurses provide direct care to their patients on a daily basis, so they know which approaches work well and which need adjusting. Nursing concerns are the heart of nursing research. even when nurses want to improve care through research findings, several barriers have hindered the progress. WHAT IS NURSING RESEARCH? Nursing research is research that provides a body of knowledge and evidence used to support nursing practices (the American Association of Colleges of Nursing, 2016) . Evidence-based practice requires using research outcomes to drive clinical decisions and care.
    [Show full text]
  • Nursing Students' Perspectives on Telenursing in Patient Care After
    Clinical Simulation in Nursing (2015) 11, 244-250 www.elsevier.com/locate/ecsn Featured Article Nursing Students’ Perspectives on Telenursing in Patient Care After Simulation Inger Ase Reierson, RN, MNSca,*, Hilde Solli, RN, MNSc, CCNa, Ida Torunn Bjørk, RN, MNSc, Dr.polit.a,b aFaculty of Health and Social Studies, Institute of Health Studies, Telemark University College, 3901 Porsgrunn, Norway bFaculty of Medicine, Institute of Health and Society, Department of Nursing Science, University of Oslo, 0318 Oslo, Norway KEYWORDS Abstract telenursing; Background: This article presents the perspectives of undergraduate nursing students on telenursing simulation; in patient care after simulating three telenursing scenarios using real-time video and audio nursing education; technology. information and Methods: An exploratory design using focus group interviews was performed; data were analyzed us- communication ing qualitative content analysis. technology; Results: Five main categories arose: learning a different nursing role, influence on nursing assessment qualitative content and decision making, reflections on the quality of remote comforting and care, empowering the pa- analysis tient, and ethical and economic reflections. Conclusions: Delivering telenursing care was regarded as important yet complex activity. Telenursing simulation should be integrated into undergraduate nursing education. Cite this article: Reierson, I. A., Solli, H., & Bjørk, I. T. (2015, April). Nursing students’ perspectives on telenursing in patient care after simulation. Clinical Simulation in Nursing, 11(4), 244-250. http://dx.doi.org/ 10.1016/j.ecns.2015.02.003. Ó 2015 International Nursing Association for Clinical Simulation and Learning. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/).
    [Show full text]
  • A Systematic Review of Omaha System Literature in Turkey
    Nursing Informatics 2016 633 W. Sermeus et al. (Eds.) © 2016 IMIA and IOS Press. This article is published online with Open Access by IOS Press and distributed under the terms of the Creative Commons Attribution Non-Commercial License. doi:10.3233/978-1-61499-658-3-633 A Systematic Review of Omaha System Literature in Turkey Selda SECGİNLİ, PhD, Associate Professor a,1, Nursen O. NAHCİVAN, PhD, Professora, Karen A. MONSEN PhD, RN, FAAN b a Florence Nightingale Nursing Faculty, Istanbul University, Istanbul, Turkey b School of Nursing, University of Minnesota and Institute for Health Informatics, Minneapolis, Minnesota, USA Keywords. Omaha System; Systematic review; Standardized terminology; Turkey 1. Introduction The Omaha System is a comprehensive tool for enhancing practice, documentation and information management across health care settings.1 This systematic review presents the state of science on the use of the Omaha System in practice, research, and education Turkey and to suggest areas for future research. 2. Methods A systematic review of the literature published between 2000 and 2014 was conducted, searching electronic databases of Ovid MEDLINE, PUB MED, Cochrane CENTRAL Register of Controlled Trials, CINAHL, PsycINFO, Web of Knowledge, Scopus, Google Scholar, ULAKBIM Turkish Medical Database and Council of Higher Education Thesis Center. The primary key word “Omaha System” and its Turkish translations were used for searching. Methodological quality of the reviewed research studies was evaluated with Joanna Briggs Institute MAStARI Critical Appraisal checklists for identifying methodological flaws in the studies included. Articles were included if studies were conducted in Turkey and published in either Turkish or English. All articles were read and then categorized to one of five categories: “analyzing client problems”, “clinical process”, “client outcomes”, “advanced classification research”, and “reports on unpublished master’s and doctoral dissertations”.
    [Show full text]
  • SYLLABUS-NURSING 3304-110 NURSING RESEARCH Texas A&M University - Central Texas Spring 2021 Texas A&M University-Central Texas
    SYLLABUS-NURSING 3304-110 NURSING RESEARCH Texas A&M University - Central Texas Spring 2021 Texas A&M University-Central Texas COURSE DATES, MODALITY, AND LOCATION Course Dates- January 19-May 14 web-based course taught online through the TAMUCT Canvas Learning Management System: [https://tamuct.instructure.com] INSTRUCTOR AND CONTACT INFORMATION Instructor: Lee Ogburn-Russell Office: On line Phone: 512-864-5090 Email: [email protected]. This is the preferred e-mail. Office Hours: Phone or synchronous online interaction can be arranged by appointment to accommodate student needs. Student-instructor interaction: Emails and messages within Canvas are checked daily. Students may expect a response within 24 to 48 hours. Office hours may also include synchronous online interaction to meet student’s learning needs and serving as a resource person to guide the student in the learning process. Other teaching strategies include online assignments, online discussion boards, a scholarly paper, and quizzes. WARRIOR SHIELD Emergency Warning System for Texas A&M University-Central Texas Warrior Shield is an emergency notification service that gives Texas A&M University-Central Texas the ability to communicate health and safety emergency information quickly via email, text message, and social media. All students are automatically enrolled in Warrior Shield through their myCT email account. Connect to Warrior Shield by 911Cellular [https://portal.publicsafetycloud.net/Account/Login] to change where you receive your alerts or to opt out. By staying enrolled in Warrior Shield, university officials can quickly pass on safety-related information, regardless of your location. COVID-19 SAFETY MEASURES To promote public safety and protect students, faculty, and staff during the coronavirus pandemic, Texas A&M University-Central Texas has adopted policies and practices to minimize virus transmission.
    [Show full text]
  • Use of Nursing Diagnosis in CA Nursing Schools
    USE OF NURSING DIAGNOSIS IN CALIFORNIA NURSING SCHOOLS AND HOSPITALS January 2018 Funded by generous support from the California Hospital Association (CHA) Copyright 2018 by HealthImpact. All rights reserved. HealthImpact 663 – 13th Street, Suite 300 Oakland, CA 94612 www.healthimpact.org USE OF NURSING DIAGNOSIS IN CALIFORNIA NURSING SCHOOLS AND HOSPITALS INTRODUCTION As part of the effort to define the value of nursing, a common language continues to arise as a central issue in understanding, communicating, and carrying out nursing's unique role in identifying and treating patient response to illness. The diagnostic process and evidence-based interventions developed and subsequently implemented by a practice discipline describe its unique contribution, scope of accountability, and value. The specific responsibility registered nurses (RN) have in assessing patient response to health and illness and determining evidence-based etiology is within the realm of nursing’s autonomous scope of practice, and is referred to as nursing diagnosis. It is an essential element of the nursing process and is followed by implementing specific interventions within nursing’s scope of practice, providing evidence that links professional practice to health outcomes. Conducting a comprehensive nursing assessment leading to the accurate identification of nursing diagnoses guides the development of the plan of care and specific interventions to be carried out. Assessing the patient’s response to health and illness encompasses a wide range of potential problems and actual concerns to be addressed, many of which may not arise from the medical diagnosis and provider orders alone, yet can impede recovery and impact health outcomes. Further, it is critically important to communicate those problems, potential vulnerabilities and related plans of care through broadly understood language unique to nursing.
    [Show full text]
  • Key Performance Indicators a Guide to Choosing, Developing and Using Kpis for Clinical Nurse/Midwife Specialists and Advanced Nurse/Midwife Practitioners
    DISCUSSION PAPER 3 Key Performance Indicators A Guide to Choosing, Developing and Using KPIs for Clinical Nurse/Midwife Specialists and Advanced Nurse/Midwife Practitioners DECEMBER 2010 KEY PERFORMANCE INDICATORS Introduction Development of healthcare in Ireland, including its structures and delivery of care, is driven by the safety and quality agenda that has become increasingly explicit in the last ten years (Department of Health and Children 2008). Nurses and midwives have contributed and continue to contribute to the enhancement of patient care and this contribution can be captured and articulated by focusing on their clinical outcomes. The National Council for the Professional Development of Nursing and Midwifery has provided focused guidance on measuring clinical outcomes in its discussion paper Clinical Outcomes (National Council 2010a). Building on that guidance, the present discussion paper has been developed as a resource for clinical nurse/midwife specialists (CNSs/CMSs) and advanced nurse/midwife practitioners (ANPs/AMPs) wishing to articulate and clarify their contribution to patient care. The need for this specialised guidance emerged from a recent evaluation of CNSs’/CMSs’ and ANPs’/AMPs’ clinical outcomes, and the final report on the evaluation contains a recommendation concerning the development of key performance indicators relevant to the roles of these nurses and midwives. The Evaluation of Clinical Nurse/Midwife Specialists and Advanced Nurse/Midwife Practitioners in Ireland Known as the SCAPE Project, the examination of CNSs’/CMSs’ and ANPs’/AMPs’ clinical outcomes involved the use of an extensive variety of research methods and date collection tools (Begley et al 2010). The study demonstrated that patient care provided by CNSs/CMSs and ANPs/AMPs improved patient outcomes, as well as being safe and cost-neutral.
    [Show full text]
  • Nursing Documentation in Clinical Practice
    From the Department of Nursing, Karolinska Institutet, Stockholm, Sweden Nursing Documentation in Clinical Practice Instrument development and evaluation of a comprehensive intervention programme Catrin Björvell Stockholm 2002 Nursing Documentation in Clinical Practice Instrument development and effects of a comprehensive education programme By: Catrin Björvell Cover layout: Tommy Säflund Printed at: ReproPrint AB, Stockholm ISBN 91-7349-297-3 NURSING DOCUMENTATION IN CLINICAL PRACTICE There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle than to initiate a new order of thing. Machiavelli, The Prince Nursing documentation in clinical practice Instrument development and evaluation of a comprehensive intervention programme Catrin Björvell, Department of Nursing, Karolinska Institutet, Stockholm, Sweden Abstract The purpose of this study was to describe and analyse effects of a two-year comprehensive intervention concerning nursing documentation in patient records when using the VIPS model - a model designed to structure nursing documentation. Registered Nurses (RNs) from three acute care hospital wards participated in a two-year intervention programme, in addition, a fourth ward was used for comparison. The intervention consisted of education about nursing documentation in accordance with the VIPS model and organisational changes. To evaluate effects of the intervention patient records (n=269) were audited on three occasions: before the intervention, immediately after the intervention and three years after the intervention. For this purpose, a patient record audit instrument, the Cat-ch-Ing, was constructed and tested. The instrument aims at measuring both quantitatively and qualitatively to what extent the content of the nursing process is documented in the patient record.
    [Show full text]
  • Letter from ANA to the Office of National Coordinator for Health IT
    November 6, 2015 Karen DeSalvo, MD, MPH, MSc National Coordinator Office of National Coordinator for Health IT Department of Health and Human Services 200 Independence Ave, SW Washington, DC 20201 Re: Comments on 2016 Interoperability Standards Advisory Best Available Standards and Implementation Specifications Submitted via: https://www.healthit.gov/standards-advisory/2016 Dear Dr. DeSalvo: The American Nurses Association (ANA) welcomes the opportunity to provide comments on the document “2016 Interoperability Standards Advisory Best Available Standards and Implementation Specifications.” As the only full-service professional organization representing the interests of the nation’s 3.4 million registered nurses (RNs), ANA is privileged to speak on behalf of its state and constituent member associations, organizational affiliates, and individual members. RNs serve in multiple direct care, care coordination, and administrative leadership roles, across the full spectrum of health care settings. RNs provide and coordinate patient care, educate patients, their families and other caregivers as well as the public about various health conditions, wellness, and prevention, and provide advice and emotional support to patients and their family members. ANA members also include the four advanced practice registered nurse (APRN) roles: nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists.1 We appreciate the efforts of the Office of the National Coordinator for Health Information Technology
    [Show full text]
  • Brush School District Re 2J District Wide School Nurse Job Description Reports To: Superintendent Terms of Employment: 169 Day W
    Brush School District Re 2J District Wide School Nurse Job Description Reports to: Superintendent Terms of employment: 169 day work year, certified salary schedule Position Summary: The purpose of the district school nurse position is to ensure that the health needs during the school day of all students in the Brush school district are addressed. The district nurse will supervise and collaborate with the Thomson licensed practical nurse. The district school nurse will oversee school health services at the district level. Principle Responsibilities: The district school nurse will: 1. Provide nursing care for the health needs of students including emergencies 2. Develop and implement health care plans 3. Participate in the identification process of children with special needs 4. Maintain student health records 5. Direct the immunization program 6. Direct the vision and hearing screening program 7. Manage communicable disease outbreaks 8. Serve as a case manager for at-risk children 9. Serve as a liaison between and resource for teachers, administrators, parents, and community health care providers 10. Conduct health assessments 11. Delegate to, train, and supervise unlicensed assistive personnel 12. Serve as the Child Care Health Consultant for the preschool and Head Start 13. Oversee school health services at the district level 14. Supervise the licensed practical nurse at Thomson POSITION REQUIREMENTS Minimum Education: Bachelor’s degree in school nursing preferred Current license to practice as a registered nurse in Colorado, Current national certification in school nursing Current certification in CPR/AED and first aid Minimum Experience: Three years of experience in school nursing preferably in pediatrics in a hospital or clinical setting At least three years as an RN, preferably in pediatrics in a hospital or clinical setting Experience in outpatient settings with long term planning would beneficial.
    [Show full text]