Author(s): Klehr J, Hafner J, Spelz LM, Steen S, Weaver K
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Abstract PURPOSE: To describe a customized electronic medical record documentation system which provides an electronic health record, Epic, which was implemented in December 2006 using standardized taxonomies for nursing documentation. DATA SOURCES: Descriptive data is provided regarding the development, implementation, and evaluation processes for the electronic medical record system. Nurses used standardized nursing nomenclature including NANDA-I diagnoses, Nursing Interventions Classification, and Nursing Outcomes Classification in a measurable and user-friendly format using the care plan activity. CONCLUSIONS AND IMPLICATIONS: Key factors in the success of the project included close collaboration among staff nurses and information technology staff, ongoing support and encouragement from the vice president/chief nursing officer, the ready availability of expert resources, and nursing ownership of the project. Use of this evidence-based documentation enhanced institutional leadership in clinical documentation.
This article was published in Int J Nurs Terminol Classif
and referenced in Journal of Neonatal Biology