Chapter 16
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Nursing Documentation in the Age of the EHR

Author Additions to Chapter 16

 

Websites That Expand on Chapter 16's Knowledge

 

ANA Involvement

Background of ANA Involvement. Some good history. Unfortunately, NIDSEC mentioned here is no longer is active.
http://users.stargate.net/~lqthede/CNPII/ANA/ANAInitiativesPage.htm

Pace, Diane (2008). ANA Committee for Nursing Practice Information Infrastructure. Article from the Tennessee Nurse describing the role of the CNPII.
http://findarticles.com/p/articles/mi_m5PXR/is_1_69/ai_n25003008/

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Standardized Terminology Articles

Zielstorff, Rita. (1998) Characteristics of Nomenclature from Informatics Perspective. Online Journal of Issues in Nursing 3(2). Written by one of the best clinical nursing informaticists, this article still has excellent ideas.
http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/
TableofContents/Vol31998/No2Sept1998/CharacteristicsofNomenclaturefrom
InformaticsPerspective.html

Other articles on this subject can be found at
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
OJIN/JournalTopics/WhatsinaName.aspx

Lundberg, C., Warren, J.., Brokel, J., Bulechek, G., Butcher, H., McCloskey Dochterman, J., Johnson, M., Mass, M., Martin, K., Moorhead, S., Spisla, C., Swanson, E., & Giarrizzo-Wilson, S. (June, 2008). Selecting a Standardized Terminology for the Electronic Health Record that Reveals the Impact of Nursing on Patient Care. Online Journal of Nursing Informatics (OJNI) 12 (2). An excellent article that describes each terminology and how they are integrated into SNOMED-CT. Each author is an expert in one of the realms addressed.
ojni.org/12_2/lundberg.pdf

ICNP Catalogues. This site has a current list of all the ICNP catalogues available for use.
http://www.icn.ch/pillarsprograms/icnpr-catalogues/

NANDA History. Divided into decades, this site provides an accurate picture of the development of NANDA. (Added October 16, 2009)
http://www.nanda.org/AboutUs/History.aspx

Nursing Problem List Subsets of SNOMED CT. "The SNOMED CT® encoded Nursing Problem List Subset, intended for use in patients’ problem lists, is an output of the Unified Medical Language System® (UMLS®) Metathesaurus® that is based on nursing diagnosis concepts found within the Metathesaurus."
http://www.nlm.nih.gov/research/umls/Snomed/nursing_problemlist_subset.html

SNOMED-CT History and other information.
http://en.wikipedia.org/wiki/SNOMED_CT#History

Schwirian, P, & Thede, L. (2011).Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses’ Experiences and Attitudes. Online Journal of Issue in Nursing 16(2).
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
OJIN/TableofContents/Vol-16-2011/No2-May-2011/Standardized-Nursing-Terminologies.html

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Value of Nursing

Morris, K. (2010) Nursing Makes Cents: Finding the Dollars in What Nurses Do. An excellent article focusing mainly on the intensity of nursing care which is the one nursing specific item from the Nursing Minimum Data Set that none of the terminologies address. Links to some excellent resources at the end. Addresses one of the missing values in current nursing terminologies, "nursing intensity." Great list of references as to how to determine nursing costs.
http://www.ohnurses.org/AM/Template.cfm?Section=Nursing_Makes_Cents_The
_Economic_Value_of_Registered_Nursing&Template=/CM/ContentDisplay.cfm&
ContentID=5197

Thede, L.Q. (2008). Informatics: The Electronic Health Record: Will Nursing Be on Board When the Ship Leaves? Online Journal of Issues in Nursing 3(2). A discussion of the need for nurses to find ways to represent nursing in an electronic record.
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
OJIN/TableofContents/vol132008/No3Sept08/ElectronicHealthRecord.aspx

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Websites from the Text in Chapter 16

USA Nursing Minimum Data Set (NMDS) http://www.nursing.umn.edu/ICNP/USANMDS/

Nursing Management Minimum Data Set (NMMDS) http://www.nursing.umn.edu/ICNP/USANMMDS/

Clinical Care Classification (CCC) http://www.sabacare.com/

North American Nursing Diagnosis Association - International (NANDA-I) http://www.nanda.org/

Nursing Interventions Classification (NIC) http://www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness/
NIC (No longer available at this URL). Instead to see NICs strengths only see
http://www.nursing.uiowa.edu/cncce/nursing-interventions-classification-strengths

Nursing Outcome Classification (NOC) http://www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness/
Noc.htm (No longer available at this URL). Instead to see NOCs strengths only see http://www.nursing.uiowa.edu/cncce/nursing-outcomes-classification-strengths

Omaha Home Health Care System http://www.omahasystem.org/

Patient Care Data Set (Retired) http://www.ncvhs.hhs.gov/990518t3.pdf

Perioperative Nursing Data Set (PNDS) http://www.aorn.org/PracticeResources/PNDSAndStandardizedPerioperativeRecord/
PNDSModel/ (No longer available at this URL).

International Classification of Nursing Practice (ICNP) http://www.icn.ch/pillarsprograms/international-classification-for-nursing-practicer/

Logical Observation Identifiers Names & Codes (LOINC) http://loinc.org/

Systematized Nomenclature of Medicine (SNOMED-CT) http://www.ihtsdo.org/snomed-ct/

Alternative Billing Codes (ABC) http://www.alternativelink.com/ali/home/

NMDS. Retrieved February 11, 2011, from http://www.nursing.umn.edu/ICNP/USANMDS/

International Council of Nurses. (2010). International Nursing Minimal Data Set (i-NDMS). Retrieved February 12, 2011,
from http://www.icn.ch/pillarsprograms/international-nursing-minimum-data-set-i-nmdsseptember-2007/

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Websites from the Reference List in Chapter 16

American Nurses Association. (2007, June 5). Relationships among ANA recognized data element sets and terminologies. Retrieved February 16, 2011, from http://www.nursingworld.org/npii/relationship.htm. (No longer available at this URL)

Association of periOperating Room Nurses. (2011). The PNDS model. Retrieved February 11, 2011, from http://www.aorn.org/PracticeResources/PNDSAndStandardizedPerioperativeRecord
/PNDSModel/ (No longer available at this URL)

Center for Nursing Classification & Clinical Effectiveness. (n.d.-a). Nursing Interventions Classification (NIC). Retrieved February 13, 2011, from http://www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness/ nicoverview.htm (No longer available at this URL)

Center for Nursing Classification & Clinical Effectiveness. (n.d.-b). Nursing Outcomes Classification (NOC). Retrieved February 11, 2011, from http://www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness/ nocoverview.htm (No longer available at this URL)

Center for Nursing Minimum Data Set Knowledge. (2010, January 7). USA NMMDS. Retrieved February, 2011, from http://www.nursing.umn.edu/ICNP/USANMMDS/

Free Merriam-Webster Dictionary. (2011). Ontology. Retrieved February 10, 2011, from http://www.merriamwebster.com/dictionary/ontology

Gordon, M. (1998). Nursing nomenclature and classification system development. Online Journal of Issues in Nursing, 3(2). Retrieved from
http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
OJIN/TableofContents/Vol31998/No2Sept1998/NomenclatureandClassification.html

International Council of Nursing. (2009). Nursing matters: International Classification for Nursing Practice. Retrieved February 16, 2011, from http://www.icn.ch/images/stories/documents/publications/fact_sheets/3a_FS-ICNP.pdf

International Council of Nurses. (2011). International Nursing Minimal Data Set (i-NDMS). Retrieved March 31, 2012 from http://www.icn.ch/pillarsprograms/internationalnursing-minimum-data-set-i-nmdsseptember-2007/. (No longer available at this URL)Instead go to
http://www.icn.ch/article/3-icnp/191-international-nursing-minimumessential-data-set-i-nmds.html

International Health Terminology Standards Development Organisation. (n.d.). History of SNOWMED CT. Retrieved February 16, 2011, from http://www.ihtsdo.org/snomed-ct/history0/

Kripps, B. J. (2008). Toward standardized nursing terminology: The next steps. Caring Newsletter, 23(3), 4–8. Retrieved from http://www.thefreelibrary.com/oward+standardized+nursing+terminology%3A+the+
next+steps.-a0187327610

Lunney, M. (2008). Critical need to address accuracy of nurses’ diagnoses. Online Journal of Issues in Nursing, 13(1). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/AccuracyofNurses
Diagnoses.aspx

McCormick, K., & Jones, C. (1998). Is one taxonomy needed for health care vocabularies and classifications? Online Journal of Issues in Nursing, 3(2). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
OJIN/TableofContents/Vol31998/No2Sept1998/Isonetaxonomyneeded.aspx

Medical News Today. (2007, January 15). Hospital death rate study reveals wide variations and stresses importance of registered nurses. Medical News Today. Retrieved February 8, 2011, from http://www.medicalnewstoday.com/articles/60785.php

North American Nursing Diagnosis Association. (2011). Nursing diagnosis frequently asked questions. Retrieved February 13, 2011, from http://www.nanda.org/NursingDiagnosisFAQ.aspx#NDxBasics

Needleman, J., Buerhaus, P. I., Mattke, S., Stewart, M., & Zelevinsky, K. (2001). Nurse staffing and patient outcomes in hospitals (2001): Executive summary. Retrieved February
8, 2011, from ftp://ftp.hrsa.gov/bhpr/nursing/staffstudy/staffexecsum.pdf

Nightingale, F., & Goldie, S. M. (1997). Letters from the Crimea, 1854–1856. Retrieved from http://preview.tinyurl.com/2auahra

Regenstrief Institute. (2011). Logical Observation Identifiers Names and Codes (LOINC®) ). Retrieved February 16, 2011, from http://loinc.org/

Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 13(1). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/
OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/Standardized
NursingLanguage.aspx

Saba, V. K. (2011). Clinical Care Classification System™. Retrieved February 11, 2011, from http://www.sabacare.com/

School of Mathematics and Statistics, St. Andrews University Scotland. (2003). Florence Nightingale. Retrieved July 31, 2010, from http://www-history.mcs.st-andrews.ac.uk/Biographies/Nightingale.html

The Omaha System. (2010). Retrieved February 11, 2011, from http://www.omahasystem.org/

U.S. National Library of Medicine. (2010). SNOWMED ClinicalTerms®. Retrieved February 16, 2011, from http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html

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Created January 15, 2012

© 1999- 2013 Linda Q. Thede & Jeanne P. Sewell

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