title: Nursing documentation with NANDA and NIC in a comprehensive HIS/EPR system.
abstract: DIPS nursing documentation system facilitates that nurses can write several types of notes into the EPR. Within these notes the nurses can register NANDA diagnoses and NIC interventions with nursing activities. To choose NANDA and NIC the nurse can use a search engine, or she can choose a relevant Care plan guideline and pick the suggested diagnoses and interventions from there. Diagnoses and interventions with nursing activities registered are presented in a Care plan. When a nurse writes a note for a patient she will always be presented the Care plan and she can easy evaluate and update the Care plan.
authors.affiliation: DIPS Ltd, Norway. kare.flo@dips.no
authors.forename: Kåre
authors.initials: K
authors.lastname: Flø
mesh_terms: D004282:Documentation; D006751:Hospital Information Systems; D006801:Humans; D016347:Medical Records Systems, Computerized; D009664:Norway; D009732:Nursing Care; D009733:Nursing Diagnosis; D010347:Patient Care Planning