The International Classicfication of Nursing Practice in Electronic Health Record Provides a Standard Language for Assessments

As a provider of care, professional nurses depend on research, theories, and evidence based practice to guide the care they provide to patients. Nurses deliver care to their patients based on information they have learned through many years of school and training. Training for nurses and other providers of care is founded on theories, research, and evidence based practice in the healthcare field. Theories, research, and evidence based practice are all important for providing care to patients and each can be used in a different manner depending on the situation. Clinicians often use research based evidence to design and implement care that is high-quality and cost effective for patients. Evidence based practice can be used to provide care to patients in a steadily changing clinical environment. (PDF page 8-9). Nursing theories are frequently used as frameworks for establishing nursing care interventions and assessing

Evidenced Based Practice (EBP) is essential to enable all nurses to provide the most current up to date practises for their patients. This process involves research, systematic review of current practises, critical thinking skills, evaluation and application to the clinical setting. In addition to this, the nurse must take into account the patients’ preferences. For nurses to have professional autonomy they must be able to justify their actions and demonstrate an understanding of why they perform the tasks they do. This defines them as unique professionals judged by their knowledge and not simply by their hands on skills.

EHRs can also improve quality of nursing care by providing nurses with education on the latest in evidence based practices relating to their patients’ conditions. “In order to bridge the gap between research and practice and to improve the quality of care, evidence-based Clinical Practice Guidelines (CPGs) can be incorporated into homecare agencies’ EHRs” (Topaz, Radhakrishnan, Masterson, & Bowles, 2012, p. 25). By incorporating this technology, EHRs go further to empower nurses to make prudent care decisions based on the latest research on best practices.

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

Itroduction: Evidence-based practice is an approach to medicine that uses scientific evidence to determine the best practice (Beyea & Slattery, 2006). As nurses perform their daily tasks they must continually ask themselves, “What is the evidence for this intervention?”. Nurses are well positioned to question current nursing practices and use evidence to make care more effective. In order to improve patients’ outcomes it is the responsibility of the nurse to transition evidence-based practice into the norm, through application of daily practice (Flynn Makic, Rauen, Watson & Will Poteet, 2014). Continual evaluation of current practice must be performed to ensure the use of evidence-based practice opposed to practice based upon tradition. The implementation of evidence-based practice standardizes healthcare practices and diminishes groundless variations within care. These variations lead to the production of uncertain health outcomes (Stevens, 2013).

For over 10 years, all areas of industry have been investing in informational technology (IT). IT offers faster and more proficient care especially for the healthcare industry. Health information technology (HIT) is making significant changes in how care is being delivered and addressed for patients and healthcare workers. HIT includes electronic health records (EHR), personal health records (PHI), electronic prescribing and more. The potential list is endless. HIT provides for more accurate and efficient documentation, prescriptions, and education. The Obama administration came up with an answer to help in HIT by instituting the meaningful use. This paper will discuss the overview of meaningful use, its’ core criteria, and recommendations for additional criteria.

American Nurses Association (ANA) Standards of Professional Performance explains how all registered nurses do their work and activities consistently according to their professions that promote the wellbeing of their patients and communities (ANA, 2010a). The standards provide a mechanism to patients that they are been taken good care of and that the nurses know exactly what to do so as to provide high-quality care and the measures are in place to determine whether nursing care meets the standards. These activities are related to performance like ethics, quality of practice, education, communication, resources, leadership, environmental health, professional practice evaluation, and evidence-based practice and research. Registered nurses are responsible for their professional actions to themselves, their patients, their peers, and the community at large.

This paper will address and evaluate the research problem itself, the design of the study, the sample, how the data is collected, its limitations, and its findings. Furthermore, how does this study impact the overall nursing process?

I will methodically analyze all parts of the study to assess the validity of the article, by contrasting and comparing the information provided, with previous literature. I will try to make sure that recommendations provided by the authors are congruous with nursing practice and beneficial to the advancement of it. I will as much as possible provide in depth detail of previous studies on the same topic that either support or contradict the analysis provided by this study and its authors.

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

By focusing on overall patient care and satisfaction many areas patients are surveyed on can be improved. Once a performance standard is selected staff must develop a plan for improvement. The first step would be to research as many sources as possible to find the best evidence based practices that would work for the specific facility. This can be divided into two the two categories of direct nursing care and indirect nursing care. Direct nursing care would include implementing hourly rounding, adequate nursing staff and SBAR communication. Indirect nursing care includes availability of technology such as wireless communication, real time locating, wireless monitoring, and electronic medical records. The second step would contain education of the staff on what is to be implemented and why. The why is important for nurses to overcome any barriers that might be encountered. While nursing practice has grown based on evidence Vanhook (2009) explains the greatest barriers to evidence based practice, such as difficulty interpreting findings, limited time, and misunderstanding of research itself, and how to overcome these barriers. With phase one and two completed facilities can move forward with implementation and evaluation.

Dr. Patricia Benner is responsible for the idea that a nurse begins her career as a novice, having a sound educational base, and eventually develops into an expert nurse after a multitude of experiences in the field (“From Novice to Expert”, 2013). This paper will explore Benner’s five stages to becoming clinically competent. This paper will also discuss the use of information technology in the clinical setting, including potential benefits of electronic health records to nurses and the impact of health information technology on consumer health.

Nursing topics were grouped together so that it flowed logically together and the nurse only needed to indicate negative exceptions to a healthy assessment. This would also minimize charting and clarify problematic areas in the patient’s assessment. If a section was normal, a quick check box indicating “no problems noted” was provided.

Evidence-based practice (EBP) in nursing means making decisions about patient care on the basis of best, current, standardized practice and guidelines. According to an article, written by Dr. Kathleen Stevens, the development of evidence-based practice (EBP) is fueled by the increasing public and professional demand for accountability in safety and quality improvement in health care (Stevens, 2013). The author also mentioned in her article that the intended effect of EBP is to standardize healthcare practices to science and best evidence and to reduce illogical variation in care,

The Royal Children 's hospital Melbourne 2010 stated, documentation of the nurses are very valuable and essential for optimum communication of care because it provides sufficient evidence of the care given to patients. However, the scrutiny of nurses’ documentation had been observed especially within the nurses ' theoretical framework, Apdie/Soapie. As a means to solve this problem a cross sectional study was conducted, aimed at examining the extent to which nurses adhered to the Apdie/Soapie theoretical framework in nursing documentation at the University Hospital of the West Indies, St. Andrew Jamaica.