Promoting standardized nursing language using an electronic medical record system

Abstract

Paper-based medical record systems are becoming obsolete with the advent of electronic medical record (EMR) systems. With EMRs, patient data can be accessed instantly, patients can be tracked intelligently, and safeguards can help prevent medical errors. By integrating a universal nursing language, such as the Perioperative Nursing Data Set (PNDS), into EMR systems, nurses can document the nursing care they give to patients. This allows nurses to show the value of their role in the OR, promote nursing, and explain how their actions help meet National Patient Safety Goals. The transition to an EMR system for Jackson Health System, Miami, is discussed, including integration of the PNDS into the EMR system.

Surviving OR Computerization

“…5 A new feature at WVUH is the display of patient-flow information on large computer screens throughout the facility, including waiting rooms. The ability to see electronically what staff members in other care areas had documented (eg, administration of intraoperative medications, postoperative skin assessment, laboratory test results, special patient care equipment, type of anesthesia used) improved nursing communication and practice.…”

“…The ability to see electronically what staff members in other care areas had documented (eg, administration of intraoperative medications, postoperative skin assessment, laboratory test results, special patient care equipment, type of anesthesia used) improved nursing communication and practice. 5 A new feature at WVUH is the display of patient-flow information on large computer screens throughout the facility, including waiting rooms. In the surgical waiting areas of the hospital, patients are assigned identification numbers at the time of registration.…”

Validation of Concept Mapping Between PNDS and SNOMED CT

“…The lack of consistency in describing patient needs and care has been criticized since the nursing profession began. In fact, there are some who believe that inconsistent use of standardized vocabularies has stifled the advancement of the nursing profession 8 . Lack of a standardized language leads to numerous interpretations of data and increases the potential for error.…”

“…When documentation of the standardized languages is implemented throughout the nursing process, data extraction to identify best practices yields better results. When standardized languages are mapped with other terminology systems, then best practices can be translated further into all settings that support the terminologies 8 …”

“…Mapping also can support nurse educators as they develop educational programs and orient new staff members 8 . In particular, the PNDS is useful because it provides guidelines or templates to link nursing diagnoses, interventions, and outcomes for consistent documentation within and across perioperative settings.…”