Utilization of Nursing Classification Systems for the Depiction of the Nursing Process in Electronic Patient Records in Order to Improve Evidence-Based Nursing
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Session presented on Sunday, July 27, 2014: Learner objectives: The learner will be able to gain an understanding of the benefits for Evidence-based nursing by using nursing classification systems in electronic data records. The learner will be able to gain an understanding about the necessary requirements of nursing classification systems for an useful application in electronic data records. Nursing classification systems are continuously gaining importance in providing the framework for the nursing process and are increasingly used as basis for the evaluation of nursing practice. In addition, the use of terminologies in electronic patient records enables the quantification of data obtained from the nursing process. Data, which can not only be used for reimbursement but also for outcome research, further development of nursing knowledge, implementation of Evidence-based nursing, and the interprofessional communication. However, the discussion of requirements nursing classification systems should meet in order to fulfill the demands of being an integral instrument in electronic patient records are still sparse in the literature. Therefore, the purpose of this symposium is to discuss the adequacy of current nursing terminologies for the use in electronic patient records so that the various requirements for being a significant contribution to Evidence-based nursing practice could be met. Furthermore, the abstraction level, or the needed granulation of nursing classification systems to enable nursing documentation in an electronic patient record will be discussed. Through three presentations, this symposium will first outline the manifold aims of utilization nursing process data in electronic patient records. Next, with the aid of the European Nursing Care Pathways (ENP), the before delineated aims will be illustrated in more detail. Finally, the needed level of abstraction and granulation of nursing classification systems will be discussed by presenting results of a cross-mapping of ENP and NANDA-I.