Selecting a standardized terminology for the electronic health record that reveals the impact of nursing on patient care

C. Lundberg
Jane M. Brokel, University of Iowa
G. M. Bulechek
H. K. Butcher
K. S. Martin
S. Moorhead
C. Peterson
C. Spisla
J. J. Warren
S. Giarrizzo-Wilson


Using standardized terminology within electronic health records is critical for nurses to communicate their impact on patient care to the multidisciplinary team. The universal requirement for quality patient care, internal control, efficiency and cost containment, has made it imperative to express nursing knowledge in a meaningful way that can be shared across disciplines and care settings. The documentation of nursing care, using an electronic health record, demonstrates the impact of nursing care on patient care and validates the significance of nursing practice. As key stakeholders of the American Nursing Association recognized terminologies, NANDA, NIC, NOC, Omaha System, PNDS, and SNOMED CT describe their respective classification systems to assist administrators, nursing executives, informatics nurses, nurse managers and staff nurses to make decisions concerning the selection of a nursing terminology or a combination of nursing terminologies that best meets their organizational needs.