Successful interdisciplinary documentation through nursing interventions classification.
Automated documentation systems enable health care professionals to develop dynamic, interdisciplinary care plans. Use of a standardized nomenclature provides a common framework and language for the communication of the plan, and also can support data collection to determine best clinical practices. A comprehensive patient care record will link the interdisciplinary care plan to clinical charting and the documentation of outcomes. This article reviews efforts to improve interdisciplinary communication by computerizing the documentation system, using the Nursing Interventions Classification (NIC).
Smith
Kathleen
K
University of Colorado Hospital, Box AO21-360, 4200 E Ninth Ave, Denver, CO 80262, USA.
Smith
Vivienne
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D019985:Benchmarking; D003142:Communication; D004282:Documentation / Q000379:methods; D006040:Goals; D006751:Hospital Information Systems / Q000458:organization & administration*; D006801:Humans; D007400:Interprofessional Relations; D007587:Job Description; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D016294:Models, Nursing; D020380:Needs Assessment; D024802:Nurse's Role; D010347:Patient Care Planning / Q000145:classification*; D010348:Patient Care Team / Q000458:organization & administration*; D018875:Vocabulary, Controlled