Implementation of standardized nomenclature in the electronic medical record.
OBJECTIVE
To describe a customized electronic medical record documentation system which provides an electronic health record, Epic, which was implemented in December 2006 using standardized taxonomies for nursing documentation.


METHODS
Descriptive data is provided regarding the development, implementation, and evaluation processes for the electronic medical record system. Nurses used standardized nursing nomenclature including NANDA-I diagnoses, Nursing Interventions Classification, and Nursing Outcomes Classification in a measurable and user-friendly format using the care plan activity.


CONCLUSIONS
Key factors in the success of the project included close collaboration among staff nurses and information technology staff, ongoing support and encouragement from the vice president/chief nursing officer, the ready availability of expert resources, and nursing ownership of the project. Use of this evidence-based documentation enhanced institutional leadership in clinical documentation.
Klehr
Joan
J
New Beginnings Birthing Center, of Aspirus Wausau Hospital, Wausau, Wisconsin, USA.
Hafner
Jennifer
J
Spelz
Leah Mylrea
LM
Steen
Sara
S
Weaver
Kathy
K
D003200:Computer User Training; D004282:Documentation / Q000379:methods*; D004509:Education, Nursing, Continuing / Q000458:organization & administration; D057286:Electronic Health Records / Q000458:organization & administration*; D005568:Forms and Records Control; D006751:Hospital Information Systems / Q000458:organization & administration; D006801:Humans; D009731:Nursing Audit; D009733:Nursing Diagnosis / Q000145:classification / Q000458:organization & administration*; D015403:Nursing Evaluation Research; D048108:Nursing Informatics / Q000193:education / Q000458:organization & administration; D009737:Nursing Records; D009741:Nursing Staff, Hospital / Q000193:education; D017063:Outcome Assessment, Health Care; D010347:Patient Care Planning / Q000145:classification / Q000458:organization & administration*; D011367:Professional Staff Committees / Q000458:organization & administration; D016730:Program Development; D015397:Program Evaluation; D018875:Vocabulary, Controlled; D014922:Wisconsin