DOCSLIB.ORG

Nursing Data Standards

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Nursing Data Standards 12 Nursing Data Standards Nursing Values Related to Health Information The initial systems for gathering minimum uniform health data can be traced back to systems devised by Florence Nightingale over a century ago (Verney 1970). Nightingale (1859) asserted the need for nurses to use their powers of memory and nonsubjective observation to track the condition of those in their care. Subsequently (Nightingale 1863), she provided forms and def- initions for the collection of uniform hospital statistics. In conclusion, she wrote (Nightingale 1863): I am fain to sum up with an urgent appeal for adopting this or some uniform system of publishing the statistical records of hospitals. There is a growing conviction that in all hospitals, even in those which are best conducted, there is a great and unnecessary waste of life;...Itis imperative that this impression should be either dissipated or confirmed. In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison...ifwisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have any means of obtaining at present. They would enable us, besides, to ascertain the influence of the hospital...upon the general course of operations and diseases pass- ing through its wards; and the truth thus ascertained would enable us to save life and suffering, and to improve the treatment and management of the sick and maimed poor. The needs have not changed. Nurses must be able to manage and process nursing data, information, and knowledge to support patient care delivery in diverse care delivery settings (Graves and Corcoran, 1989). Ozbolt, (1999) maintained that: Standard terms and codes are needed to record as structured data the problems and issues that nurses and other caregivers address; the actions they take to prevent, 171 172 Infrastructure Elements of the Informatics Environment ameliorate, or resolve the problems; and the results of their care. Such data could be used to increase the effectiveness of care and control costs. There is an essential linkage among access to information, client outcomes and patient safety. “As Lang has succinctly and aptly described the present situation: If we cannot name it, we cannot control it, finance it, teach it, research it or put it into public policy” (Clark and Lang, 1992). Access to information about their practice arms nurses with evidence to support the contribution of nursing to patient outcomes. Outcomes research is an essen- tial foundation for evidence-based nursing practice. Evidence-based practice is a means of promoting and enhancing patient safety. Evolution of Nursing Information and Nursing Data Elements There are a variety of concepts that interlink when considering the capture of nursing practice data. Figure 12.1 illustrates the derivation, from nursing practice, of nursing classification, nursing terminology, min- imum data sets, reference terminology models, and the resulting feedback loop. FIGURE 12.1. Relationships between nursing practice and classification, terminology, minimum data sets, and reference terminology model. Nursing Data Standards 173 United States Uniform Hospital Discharge Data Set In the United States, the Uniform Hospital Discharge Data Set (UHDDS) was developed over a 5-year period during the early 1970s. It identified the minimum basic set of data elements to be collected from all hospital records at the point of patient discharge from hospitals. In 1974, the UHDDS was adopted and mandated by the Secretary of the Department of Health and Human Services for collection by the U.S. National Committee on Vital and Health Statistics (Abdellah, 1988; Pearce, 1988). The UHDDS provided the model for the hospital discharge abstract that was subsequently developed in Canada and ultimately evolved into the Discharge Abstract Database (DAD), now maintained by the Canadian Institute for Health Information (CIHI). The care items included in the UHDDS focused on physician-derived clinical data (specifically,medical diagnosis and procedures based on medical treatments). There were absolutely no nursing clinical data included in this data set. Patient care is not exclusively physician-directed; therefore, a data set of this nature falls short of providing a complete, accurate representation of information related to the operation of hospitals. Nursing Minimum Data Set In response to recognition of the information gap created by the exclusion of nursing data elements from the Uniform Hospital Discharge Data Set, Werley and colleagues developed the Nursing Minimum Data Set (NMDS) through a consensus conference at the University of WisconsinMilwaukee School of Nursing in 1985 (Werley and Lang 1988). The NMDS was defined as “a minimum set of items of information with uniform definitions and categories concerning the specific dimension of professional nursing, which meets the information needs of multiple data users in the healthcare system” (Werley and Lang 1988). There were five purposes of the NMDS. r Establish comparability of nursing data across practice settings and geo- graphic boundaries r Capture descriptors reflecting the nursing care of clients and their families in a variety of settings r Project trends in nursing care needs and resource use according to health problems r Provide a database for nursing research r Provide data about nursing care for consideration by individuals involved in health policy decision-making The NMDS consisted of nursing care elements, patient demographic ele- ments, and service elements. The nursing care elements of nursing diagnosis, nursing intervention, nursing outcome, and intensity of nursing care drew 174 Infrastructure Elements of the Informatics Environment on the nursing process used by nurses to plan and provide patient care in any setting. The patient demographic and service elements, except health record number and the unique number of the nurse provider, are data elements con- tained in the UHDDS and could be accessed through linkage with this data set (Werley and Lang, 1988). Once the NMDS was agreed upon, uniform definitions for each of the data elements and standard classification systems were necessary for collection of uniform, accurate data to be feasible. Classification Systems for NMDS Data Elements The North American Nursing Diagnosis Association (NANDA) initiated the development of labels for the clinical phenomena for which nurses provide care (i.e. nursing diagnosis) in 1973. NANDA has defined nursing diagnosis as “a clinical judgment about individual, family, or community responses to actual and potential health problems and life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes of which the nurse is accountable” (Carpenito, 1989). The Visiting Nurses Association (VNA) of Omaha developed the problem classification scheme, intervention scheme, and problem rating scale for out- comes related to community health client problems and nursing problems used for documenting community health nursing services. The Omaha classi- fication system defined a problem as “a clinical judgment about environmen- tal, psychosocial, physiologic and health related behavior data that is [sic]of interest or concern to the client” (Martin, 1988; Martin and Scheet 1992). The Home Healthcare Classification (HHCC) was developed at the Georgetown University School of Nursing from 1988 to 1991 to assess and classify home health Medicare clients for predicting their need for nursing and other home care services as well as for measuring outcomes and data on the resources employed (Saba, 1992). Nursing interventions were defined in the HHCC: Nursing Interventions as a nursing service, with significant treat- ment, intervention, or activity identified to carry out the medical or nursing order (Saba, 1992). Nursing interventions were considered critical measures of the resources used. The Nursing Interventions Classification (NIC) and Nursing Outcomes Classification System (NOC) were developed by a large research team (the Iowa Intervention Project) led by McCloskey and Bulechek at the University of Iowa. This team defined nursing interventions as “any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance pa- tient/client outcomes. Nursing interventions include both direct and indirect care; both nurse-initiated, physician-initiated and other-provider-initiated treatments”(McCloskey and Bulechek, 1996). NIC was coded to be consis- tent with the Current Procedural Terminology, American Medical Associ- ation, and the Healthcare Financing Administration’s Common Procedure Coding System and was included in the Library of Medicine’s Metathesaurus for a Unified Medical Language. Additionally, it has been endorsed by the Nursing Data Standards 175 American Nurses Association (ANA) for inclusion in the proposed Unified Nursing Language System (McCloskey and Bulechek, 1996; McCormick et al., 1994). NIC provides a standardized language that can be used across settings and across healthcare disciplines (McCloskey and Bulechek, 1996). Independent and collaborative interventions as well as basic and complex interventions were included. A nursing outcomes classification (NOC) sys- tem has also been developed in conjunction with the NIC through the Iowa Intervention Project Johnson et al., 2000). The Unified Medical Language System (UMLS) includes NANDA, the
Load more

Recommended publications
  • Nursing 1 Nursing
    Nursing 1 Nursing For other uses, see Nursing (disambiguation). "Nurse" redirects here. For other uses, see Nurse (disambiguation). Nurse A British nurse caring for a baby in 2006 Occupation Names Nurse Occupation type Healthcare professional Activity sectors Nursing, Health care Description Competencies Caring for general well-being of patients Education required Qualifications in terms of statutory regulations according to national, state, or provincial legislation in each country Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses may be differentiated from other health care providers by their approach to patient care, training, and scope of practice. Nurses practice in a wide diversity of practice areas with a different scope of practice and level of prescriber authority in each. Many nurses provide care within the ordering scope of physicians, and this traditional role has come to shape the historic public image of nurses as care providers. However, nurses are permitted by most jurisdictions to practice independently in a variety of settings depending on training level. In the postwar period, nurse education has undergone a process of diversification towards advanced and specialized credentials, and many of the traditional regulations and provider roles are changing. Nurses develop a plan of care, working collaboratively with physicians, therapists, the patient, the patient's family and other team members, that focuses on treating illness to improve quality of life. In the U.S. (and increasingly the United Kingdom), advanced practice nurses, such as clinical nurse specialists and nurse practitioners, diagnose health problems and prescribe medications and other therapies, depending on individual state regulations.
    [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]
  • 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]
  • Assignment Is a Complementary Relationship Between Nurse and Bhts and Bhas That Results in Safe and Efficient Patient Care If It Is Used Appropriately
    Unity Center for Behavioral Health Assignment is a complementary relationship between nurse and BHTs and BHAs that results in safe and efficient patient care if it is used appropriately. It is a critical step in the delivery of nursing care. This Photo by Unknown Author is licensed under CC BY-SA-NC 1) Define assignment and how it relates to nursing practice. 2) Explain the difference between assignment and delegation. 3) Define the roles and responsibilities within assignments of BHTs and BHAs. 4) Review the the correct steps when assigning tasks to BHTs and BHAs. 5) Review assignments, ethics and standards specific to the psychiatric mental health nurse. Assignment has a specific meaning in the Nurse Practice Act. OAR 851-06 defines the term assign as “...directing and distributing, within a given work period, the work that each staff member is already authorized by license or certification and organizational position description to perform.” Unlicensed assistive personnel (UAP) are unlicensed health care providers trained to function in a supportive role by providing patient/client care activities. When the activity to be performed is within the UAP’s position description, and there is documented education and current competency validation of the UAP having been done by the organization employing both the RN and the UAP staff member. The UAP is held accountable for the performance of their role. KEY POINT: The RN, determines the appropriate match between the patient and BHT or BHA, and assigns a task to the BHT or BHA based on their competency and job description. If a BHT or BHA does not perform their assigned task, the RN is NOT held responsible.
    [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]
  • Nurse Life Care Plan for (Client) - Table of Contents
    NURSE LIFE CARE PLAN for (Client) ©2011, Shelene Giles Methodology The American Nurses Association (ANA) defines nursing as the protection, promotion, and optimization of health and abilities; prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. The human response includes the response of the individual and family to actual or potential health problems. ANA notes “…Nurses are educated to be attuned to the whole person, not just the unique presenting health problem. While a medical diagnosis of an illness may be fairly circumscribed, the human response to a health problem may be much more fluid and variable and may have a great effect on the individual’s ability to overcome the initial medical problem. In what some describe as a blend of physiology and psychology, nurses build on their understanding of the disease and illness process to promote the restoration and maintenance of health in their clients…Nursing is a key element in patient survival as well as in the maintenance, rehabilitation, and preventive aspects of healthcare.." (ANA Nursing's Social Policy Statement, Second Edition, 2003). The American Association of Nurse Life Care Planners (AANLCP) defines nurse life care planning as utilizing the nursing process in the collection and analysis of comprehensive client specific data in the preparation of a dynamic document. This document provides an organized, concise plan of estimated reasonable and necessary, current and future healthcare needs with the associated costs and frequencies of goods and services. The Nurse Life Care Plan is developed for individuals who have experienced an injury or have chronic healthcare issues.
    [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]
  • American Psychological Association 5Th Edition
    NURSING DIAGNOSES IN THE CARE OF HOSPITALIZED PATIENTS WITH TYPE 2 DIABETES MELLITUS: PATTERN ANALYSIS AND CORRELATES OF HEALTH DISPARITIES Kennedy O. Onori A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Philosophy in the School of Nursing. Chapel Hill 2013 Approved by: _ Edward J. Halloran, PhD, RN, FAAN Lorna H. Harris, PhD, RN, FAAN Allison A. Vorderstrasse, DNSc, RN Shielda G. Rodgers, PhD, RN Jamie L. Crandell, PhD © 2013 Kennedy O. Onori ALL RIGHTS RESERVED ii ABSTRACT KENNEDY O. ONORI: Nursing Diagnoses in the Care of the Hospitalized Patient with Type 2 Diabetes Mellitus: Pattern Analysis and Correlates of Health Disparities (Under the direction of Edward J. Halloran, RN, PhD, FAAN) This study examined the human needs of 445 adults admitted to hospital with the primary medical diagnosis of Type 2 Diabetes Mellitus [ICD-9CM 250.0-9] and compared the pattern of nursing diagnoses (human needs) with those of 5321 patients having Type 2 DM but admitted to hospital for other reasons and with the 78,480 inpatients with no DM. Length of hospital stay, intensive care unit use and discharge dispositions were examined, controlling for race, poverty, marital status and age, to determine if the nursing diagnosis variables were distinctive for any of the three patient groups. A subset of 14 nursing diagnoses was identified from the literature on the care of Type 2 DM to determine how they varied among the three groups. The 61 nursing diagnoses were also fitted in regression models to explain variances in patient length of stay and to explore patient diabetes status.
    [Show full text]
  • Barriers to Implementation of Nursing Process Among Nurses Working in Narok County Referral Hospital
    BARRIERS TO IMPLEMENTATION OF NURSING PROCESS AMONG NURSES WORKING IN NAROK COUNTY REFERRAL HOSPITAL LEKENIT SARETIN ANNA A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE CONFERMENT OF DEGREE OF MASTER OF SCIENCE IN NURSING EDUCATION OF KENYA METHODIST UNIVERSITY OCTOBER 2020 DECLARATION ii DEDICATION This research is dedicated to all nurses in Narok County both private and public sector. iii ACKNOWLEDGEMENT God almighty, receive glory and Honour for having given me good health, finances and time during the entire period of my research project development. I also acknowledge my research supervisors Prof. Ruth Gathigia Gatere and Dr. Agnes Mutinda Kasusu for their guidance and advice. Lastly, I sincerely recognize my Husband Mr. Murrey, my daughter Muriel, my sister Alison and my entire family for their time, contribution and input towards my research project. iv ABSTRACT Globally, nursing process has gained popularity and is utilized in hospitals to offer quality individual nursing care to patients. It is utilized by nurses in clinical setup to offer quality nursing care to patients individually as unique and having special needs. Nursing process non-implementation can lead to poor nursing care to patients in healthcare institutions. This study therefore assessed barriers of nursing process implementation by Narok County Referral Hospital (NCRH) nurses. A descriptive cross sectional study design was used to collect data from 102 conveniently sampled nurses in NCRH. The study instruments used were self-administered questionnaires and key informant interview. SPSS version 20.0 was used to analyze quantitative data and sample characteristics were analyzed using mean and median. Qualitative data was thematically analyzed and presented in tables.
    [Show 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.
    [Show full text]
  • The Right to Get Good Nursing Care
    THE RIGHT TO GET GOOD NURSING CARE Babone, Kofi 2009 Otaniemi Laurea University of Applied Sciences Otaniemi THE RIGHT TO GET GOOD NURSING CARE Kofi Babone Degree programme in nursing Thesis March, 2009 2 Laurea University of Applied Sciences ABSTRACT Otaniemi Degree programme in Nursing Kofi Babone The right to get good nursing care Year 2009 Pages 47 The purpose of this thesis is to find out nurses’ descriptions of the implementation of the act of the patient rights with pulmonary disease in HUS Jorvi hospital and how the nurses implement the act of the patient rights in their own ward. This thesis aimed at collecting data from nurses at a hospital ward. The research ques- tions are: What are pulmonary patients’ rights according to the act described by nurses and how do nurses implement the patient rights in their own ward. The method of qualitative nursing research was conducted in this thesis. Focus group interviewing was the research method. The informants (n = 5) of this thesis were regis- tered nurses. They worked on a pulmonary ward in HUS Jorvi hospital, Espoo, Finland. The interview was implemented in December 2008. The collected data was analysed by using inductive content analysis. In this thesis the findings propose that the funda- mental rights of the patients on pulmonary ward are individuality, co-operation and nursing, which have sub-categories of equality, needs, privacy, information, decision- making, opinions, primary nursing, delicate nursing and specialised nursing. As a unit- ing category to all these rights was the right to get good nursing care. The implementa- tion of these rights on pulmonary ward complied relatively well with the views of the nurses.
    [Show full text]