The promise of simultaneous transformation of practice and research with the use of clinical information systems

Identifying the barriers to use of standardized nursing language in the electronic health record by the ambulatory care nurse practitioner

“…As EHR vendors include SNOMED‐CT in their products, this may be the vehicle needed to provide access to SNL in EHRs. Lang (2008) has described a 5‐year vision for the transformation of nursing practice and research utilizing computerized CISs with reference terminologies such as SNOMED‐CT to document nursing care, to enhance decision making, and to improve nurse‐sensitive outcomes for patients across patient care settings.…”

Write the Wrong: Narrative Documentation

“…They include issues such as lack of structure in the data entered, ambiguity of expression, redundancy in care capture, a host of transcription and cognitive errors, and limited opportunities for aggregation or reuse in databases or by clinical decision support systems. [2][3][4][5] Let's begin with an example that demonstrates many of the concerns above. In Table 1, there is a narrative note that captures many of the pertinent aspects of Phase I postanesthesia care.…”

Enhancing electronic medical record retrieval through semantic query expansion

“…Other knowledge engineering efforts may provide additional useful inputs. For example, the Knowledge-Based Nursing Initiative (KBNI) jointly conducted by Aurora, Cerner, and the University of WisconsinMilwaukee (Lang 2008) aims at identifying actionable knowledge from the nursing research literature to inform nursing practice and decision making. The KBNI project produces practice recommendations for assessment, diagnosis, intervention, and outcome with regard to a set of important nursing phenomena of care.…”