Introduction. This Paper Provides A Discussion Of The Electronic

2008). Another system focused on patient scheduling in a rehabilitation setting (Ozbolt, J.G., Saba, V.K. 2008). Nurses at a California hosptial assisted in developing the first comprehensive hospital information system and helped integrat the system for nursing care planning, documentation, and feedback (Ozbolt, J.G., Saba, V.K. 2008). They developed the standard care plans that are used throughout the world today (Ozbolt, J.G., Saba, V.K. 2008). Another big achievement of this decade was the introduction of the first commercial electronic medical record (Thede, L. 2012). This new system was patient-oriented and was implemented throughout the hospital (Thede, L. 2012).

Wilkinson, J. M., & Treas, L. S. (2016). Fundamentals of Nursing (3rd ed., Vol. 1). Philadelphia, PA: F.A.

Nursing theory has three distinct categories to describe the level of abstraction: Grand, Middle-Range, and Situation-Specific (Meleis, 2012, p. 33). Hugh McKenna (1997) defined these three categories, stating:

The profession of nursing has, in recent years, been trying to further develop, test and use proposed nursing theory. To utilize theory appropriately, in all domains of practice, education and research, it is important to know how to describe, analyze and evaluate

A. Nurse sensitive indicators are factors that are directly impacted by nursing.  There indicators fall into three categories; structure, process and outcomes of nursing care.  The structure indicators are the organizational piece of nursing care. These relates to the amount of staff on duty at a given time, how many RN's are on duty and experience level of the staff. For example, evidence indicates institutions with a higher number of RN’s possessing a Bachelor Degree in nursing result in improved patient outcomes. The process indicators measure nursing care such as patient assessment, patient care and intervention. These are the organizational policies and procedures of nursing.   The patient outcomes are indicators directly related to

a. The label is the title of the nursing diagnosis as defined by the North American Nursing Diagnoses Association (NANDA).

Nursing sensitive indicators include the configuration, process and outcomes of nursing care. The configuration of nursing care concludes the nursing staff, their nursing skills, and the level of education that each nurse holds. The process of nursing care concludes the nursing assessments, intervention and implimentation. The outcome of nursing care either positive or negative depends on the quantity and quality of the care provided to the patients by the nursing staff ("Nursing world," 2013)

Nursing- sensitive indicators are defined as those outcomes that improve in the presence of greater quantity(higher staffing ratios) or quality(educational levels and competence of nursing staff) of nursing care (www.nursingworld.org). These nursing-sensitive measures help healthcare organizations to analyze the quality and quantity of nursing care services. (www.americansentinel.edu )Nursing sensitive-indicators (NSIs) are characterized by measures that are in the realm of nurses to improve and control. According to the website www.nursingworld.org , in 1998, the National Database of Nursing Quality Indicators was established by the ANA so that

They serve as a framework for clinical assessment and can be applied to the individual, family, and community. Through this framework, data is collected and assessed, allowing for the application of nursing diagnoses and interventions that encompass a holistic view of the client. There are 11 patterns, and within each pattern there are four focal areas.

Nursing care is focused on the assessment, nursing diagnoses, planning, implementation, and evaluation of patients. This nursing process can also be implemented in aspects outside of nursing and on the nursing field as a collective group. The nursing role is evolving, following the process the outcomes have to be evaluated and put into perspective. Research is being completed the conclusions are all the same, the higher education of nursing care the better the patient outcomes.

To further evaluate the usefulness of the 5 remaining articles, their abstracts were read to identify any relevant information. Information is data that has some meaning to it. Davenport and Prusak (1989) describes information as data that makes a difference to the receiver of the data. The data which is now aggregated into informational sentences and paragraphs (complete thoughts) reveal that the NANDA Nursing Diagnoses, the Iowa Nursing Interventions, and Iowa Nursing Outcomes Classification SNLs have been explored for use in Nurse Practitioner practice. This is information as it has context to the reason the literature search is being performed.

As a result of the introduction of computer technology and the combination of evidence-based practice in nursing; standardization of terminologies has become imperative in the classification of nursing diagnosis, interventions and expected outcomes. The most popular and successful systems are the North American Nursing Diagnosis Association International (NANDA-I), Nursing Outcomes Classification (NOC), and Nursing Intervention Classification (NIC) (de Lima Lopes, de Barros, & Marlene Michel, 2009). This paper aims to provide a brief outline of these standardized terminologies (STs) as they relate to a

The International Classification of Nursing Practice (ICNP) in the Electronic Health Record (EHR) provides a standardized language for nursing assessment documentation. The ICNP is a standardized nursing language that promotes unity among existing nursing standards and demonstrates the nurses’ contribution to health care (McGonigle &Mastrian, 2012). A term is known as a word or a phrase. Nursing terminology is a group of terms used to collect, represent, or communicate data and information collected by the nurse. Standardization of nursing terminology is accepted by a proper authority and is implemented throughout all nursing practices (McGonigle &Mastrian, 2012). This means nursing language is used locally, nationally, and internationally. Even though there are gaps in using the ICNP in the EHR for nursing assessment documentation, there are many benefits of using evidence based assessment terminology. In this paper, the benefits of using this evidenced based assessment terminology for documentation, how it contributes to research, and how it contributes to electronic documentation will be discussed.

Every profession has standardized terminology as seen in generalized nursing practice. Harriet Werley promoted the development of the Nursing Minimum Data Set (NMDS), which consists of a minimum set of items of information with uniform definitions and categories concerning the specific dimension of nursing which meets the information needs of multiple data users in the health care system (as cited in Schwirian & Thede, 2012). The NMDS consist of diagnoses, interventions, & outcome which has been further standardized by the American Nurses Association with specific terminologies. Advance practice nursing roles is often a mix of leadership and or direct clinical care where interdisciplinary communication is part of the standardized practice for

Nurses, and the tasks they do are the working units of any medical establishment. The field of nursing is a unique occupation, a mixture of the medical and hospitality fields. A nurse must be well equipped to perform medical care while also comforting their patients. To accomplish this feat, a specialized language has been developed consisting of medical terminology, extensive documentation, and body language. With such a large amount of complicated information being transferred in medical occupations, naturally, there are many variations of the standard “nursing language”. Currently, the American Nurses Association has approved thirteen languages that support nursing care. With this lack of consistency and no standard