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documentation, electronic health records, informatics, nursing research, nursing theory, spirituality, standardized terminology



  1. Burkhart, Lisa PhD, RN
  2. Androwich, Ida PhD, RN, FAAN


Nursing is at a critical juncture in creating data repositories that support nursing research and theory development, as health systems adopt and design electronic health records. This article discusses how informatics theory can be used to guide designing nursing documentation screens and analyzing the resulting data sets, while highlighting methods to maximize reliability and validity and to address measurement issues. Examples will be applied to spiritual care, a required dimension of care. These examples present methods to capture and study "soft" areas of nursing that have not traditionally been documented or measured.