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Clinical information system, CIS, Documentation, Low birth weight, NMDS, Nursing Minimum Data Set, Omaha System





If the Nursing Minimum Data Set elements, specifically the nursing care elements, are included in a clinical information system, nursing will be able to measure outcomes and contributions to both healthcare and nursing to build knowledge using clinical data. The purpose of the reported study was to determine whether a Nursing Information and Data Set Evaluation Center-compliant clinical information system using the Omaha System could support the Nursing Minimum Data Set goal to describe nursing care in a community health setting. The secondary data set analysis was conducted. The findings showed that although the clinical information system was compliant with the standard, used a recognized American Nurses Association nursing vocabulary, and supported the collection of the Nursing Minimum Data Set, the data were not sufficient to address the purposes of the Nursing Minimum Data Set. The implications for nursing research and clinical practice are outlined.