Introduction. This Paper Provides A Discussion Of The Electronic

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This paper provides a discussion of the Electronic Health Record for healthcare, explains why it is important for nursing to have a standard nomenclature for nursing care, and compares and contrasts two of the nursing terminologies currently recognized by the American Nursing Association.
"Organized information allows inferences to be made that answer questions greater than those answered by the information alone." (Moss, Damrongsak, & Gallichio, 2005, p. 545).
Medical care is making a switch to Electronic Health Records. The Office of the National Coordinator for Health Information Technology provided incentives to hospitals and other medical institutions to use electronic health records for "Meaningful Use" (Saba
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Selecting one standard that codes nursing services would allow nurses to prevent these services as codes for cost and for Nurse Practitioners involved in government to be a significant part of Meaningful Use legislation going forward.
The American Nurses’ Association recognizes 12 standardized (including nursing specific and interdisciplinary) terminologies as well as data element sets (such as the nursing minimum data set), and interfaces to support nursing practice. In this paper I will specify two such sets and will compare and contrast them and provide a sample Plan of Care using each.
One of the two terminologies I have chosen to use in the comparison isn 't really one terminology, it is a combination of three, although it does have a designation. The combination of terminologies is the North American Nursing Diagnosis Association- International (NANDA-I), Nursing Intervention Classification (NIC), and Nursing Outcome Classification (NOC) (Saba & McKormick, 2015. This is informally known as NNN or NNN+.
NANDA-I was developed to allow nursing to identify and classify health problems related to nursing, organize nursing data and allow costs to be assigned to nursing (Thede & Schwirian, 2016). It has evolved from an alphabetical organization of 100 nursing diagnoses in 1973 to a taxonomy with 13 domains, 47 classes, and 205 diagnoses (Thede & Schwirian, 2016).
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