Development of Computerized Nursing Process Documentation System Using NANDA, NOC, and NIC Linkages

The nursing care plan was developed by linking the nursing diagnosis, desired nursing outcome and suggested nursing intervention based on NANDA, NOC, and NIC linkage. The fetched sentences linked with each nursing activity supports nursing documentation.
The data model uses the NNN classifications to map a possible form of the nursing process in the electronic patient health record, where the nurse can choose nursing diagnoses, outcomes, and interventions relevant to the patient situation. The nurses' choice is guided both by the different classifications and their linkages, and the use of specific text components pre-defined for each classification and accessible through the respective linkages.
The main point of the system development is to give a specific code to each nursing activity in Nursing Intervention Classification(NIC), to link an expressible recording sentence with each activity, and to try to link a related nursing cost with each activity.
Although information systems may appear to be cold and literal, there is no reason why an electronic patient records system should do anything but enhance the clinical role of the nurse by saving time and improving documentation. The process of development was as follows;
  1. An expert group must be organized to develop the computer based nursing process documentation system. The range of computerization was determined to support nursing care plan and nursing documentation, and to provide the statistical data of the nursing care plans.
  2. The expert group analyzed the care planning process and nursing documentation process. The group also determined developmental principle, standard language, basic data.
  3. Organization and arrangement of basic data, database construction, designing of the user interface system, code construction, program construction were accomplished. It is a huge database.
  4. A users manual that focuses on usage instructions, standardized nursing language and nursing process was then developed.

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