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Keywords

Computerized medical records systems, Controlled vocabulary, Nursing records, NANDA, NOC, NIC

 

Authors

  1. KEENAN, GAIL M. PhD, RN
  2. STOCKER, JULIA R. MS, RN
  3. GEO-THOMAS, ANNIE T. MS
  4. SOPARKAR, NANDIT R. PhD
  5. BARKAUSKAS, VIOLET H. PhD, RN
  6. LEE, JAN L. PhD, RN

Abstract

The consistent availability of a core set of clinical nursing data is essential to promote quality patient care. Although important work to improve terminology and enhance comparability of data is underway, the efforts do not address the immediate need for useful nursing data sets and valid methods of collection at the point of data entry. The Hands-on Automated Nursing Data System (HANDS) project is dedicated to refining a feasible methodology for gathering, storing, and retrieving a standardized nursing data set. To date the project team has developed and tested a prototype research tool that is automated and contains the structured terminologies (North American Nursing Diagnosis Association, Nursing Outcomes Classification, and Nursing Interventions Classification) to represent nursing diagnoses, outcomes, and interventions, respectively. The Phase I project development activities are reported in this article, along with Phase II and III plans for testing and refining the methodology under actual clinical conditions. Results and lessons learned during Phase I are reported.