How it used in our daily practices and why it is important for them in EHRs
NIC (Nursing Interventions Classification) and NOC (Nursing Outcomes Classification) are integrated into the NANDA clinical decision framework by practicing nurses in acute care hospitals, outpatient and ambulatory settings, rehabilitation and long term care facilities and in patient homes by nurses to help develop a standardized plan of care for patients that also have certain activities and interventions to help develop goals for positive outcomes with the treatment the patient is receiving.
These outcomes can be populated in the electronic health record assessments and with the evidence-based criteria support the decisions being made for the measurement of the outcomes and the interventions individualized to that specific patient.
It is important to use these standardized nursing terminology (SNTs) when describing and defining the nursing care that will be provided to the patients. They help provide clear definitions and concepts for the care allowing the providers and the nurses to use the same terminology to help in the description of patient problems, nursing interventions, and anticipated patient outcomes. With the EHRs the SNTs are required for nursing care plans. The EHR is now seen as the total reflection of the care being provided so the nursing diagnosis, interventions and outcomes need to be a part of this record so it can capture the nurses contributions to the care of the patient.
These SNTs provide information and need to be developed in the electronic nursing care plan in the EHR so it can become a part of the nursing care on a daily or even shift by shift basis. (Park, 2014).
The Clinical Care Classification (CCC) System is also a standardized, coded nursing terminology that can help identify certain elements of the nursing practice. There are four frameworks and certain structures for coding that are involved in recording the patient's care in all setting of the health care organization. This system is used to help document a nursing care plan using six steps by using a certain model. This model helps bring the nursing diagnosis and the nursing interventions together to help with looking at the patient's outcomes.
When converting to the EHR it is important for nurse leaders to be involved with the process to rebuild the nursing documentation system using the CCC as an organized taxonomy. By doing this it will help create a patient record that will help nursing be guided in safe, effective and efficient care and also help produce the data needed to evaluate the care provided to the individualized patients or a certain population of patients when needed. The goal is to also eliminate duplicate documentation and eliminate unnecessary information from the record that is not directed to the care provided. The use of the CCC in the electronic health record can help clarify, document and communicate the elements of care among the nurses and help improve outcomes and collaborate processes. (Englebright, Aldrich & Taylor, 2014).
References:
Englebright, J., Aldrich, K., & Taylor, C. R. (2014). Defining and incorporating basic nursing care actions into the electronic health record. Journal Of Nursing Scholarship: An Official Publication Of Sigma Theta Tau International Honor Society Of Nursing / Sigma Theta Tau, 46(1), 50-57. doi:10.1111/jnu.12057
Park, H. (2014). Identifying core NANDA-I nursing diagnoses, NIC interventions, NOC outcomes, and NNN linkages for heart failure. International Journal Of Nursing Knowledge, 25(1), 30-38. doi:10.1111/2047-3095.12010
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