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Nursing Documentation in Digital Solutions

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Introduction to Nursing Informatics

Part of the book series: Health Informatics ((HI))

Abstract

Information plays a vital role in the nursing process. The information aggregated by registered nurses in a wide range of records across the breadth of practice underpins and can bring about services that will support global populations into the next decade and beyond.

Nurse leaders need to be able to translate, synthesise, interpret and manage that information into measurable outcomes. The impact of knowledgeable and enthusiastic Executive Nurses who provide and develop informatics leadership is essential to build both the art and science of nursing into the next decade.

In terms of how nursing data is captured and structured to effectively do that, no one type of clinical data will accommodate the spectrum of nursing and midwifery practice for every scenario but in determining the most appropriate type of data or combination of data types, the advantages and disadvantages of each should be considered, as well as the workflows and downstream effects of capturing data.

Much work has been completed in the last 20 years to advance thinking around the use of nursing Standardised Terminologies. The findings from the identified studies cited demonstrate benefits of using Standardised Terminologies although it is difficult to determine whether STs impact directly on patient outcomes or the time efficiency of end-users. The careful implementation, education and support of nurses and midwives to utilise STs as well as a well-designed, user-friendly EHCR system contributes to its use and the benefits derived.

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Author information

Authors and Affiliations

  1. Health Service Executive, Dublin 8, Ireland

    Loretto Grogan

  2. Five Country Nursing and Midwifery Digital Leadership Group, Belfast, Ireland

    Loretto Grogan

  3. Northern Ireland Practice and Education Council for Nursing and Midwifery, Belfast, UK

    Angela Reed

  4. Five Country Nursing and Midwifery Digital Leadership Group, Belfast, UK

    Angela Reed

  5. ICHEC, Irish Centre for High-End Computing, Dublin, Ireland

    Orna Fennelly

Authors
  1. Loretto Grogan
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  2. Angela Reed
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  3. Orna Fennelly
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Correspondence to Loretto Grogan .

Editor information

Editors and Affiliations

  1. School of Nursing, Psychotherapy and Community Health, Center of eIntegrated Care, Dublin City University, Dublin, Ireland

    Pamela Hussey

  2. Center of Excellence, Gevity Consulting Inc and Kennedy Health Informatics Inc, Halifax, NS, Canada

    Margaret Ann Kennedy

7.1 Electronic Supplementary Material

Data 1

Educational Template (PPTX 50 kb)

Glossary

ABC

Billing Codes

CCC

Clinical Care Classification

CDS

Clinical Decision Support

EHCR

Electronic Health Care Record

HCP

Health Care Professional

ICD

International Classification of Diseases

ICNP

International Classification for Nursing Practice

ICPC

International Classification of Primary Care

IoT

Internet of Things

LOINC

Logical Observation Identifiers Names and Codes

NANDA

North American Nursing Diagnosis Association

NANDA I

North American Nursing Diagnosis Association International

NIC

Nursing Intervention Classification

NLP

Natural Language Processing

NOC

Nursing Outcome Classification

OPCS

Office of Population Censuses and Surveys Classification of Interventions and Procedures

PNDS

Peri Operative Nursing Dataset

SDH

Social Determinants of Health

SNOMED CT

Systematized Nomenclature of Medicine—Clinical Terms

ST

Standardised Terminologies

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Grogan, L., Reed, A., Fennelly, O. (2021). Nursing Documentation in Digital Solutions. In: Hussey, P., Kennedy, M.A. (eds) Introduction to Nursing Informatics. Health Informatics. Springer, Cham. https://doi.org/10.1007/978-3-030-58740-6_7

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