Journal of Nursing and Health Studies

Strengths and weaknesses of standardized nursing terminologies used in electronic health records: a literature review

EuroSciCon Event on Nursing Diagnosis & Midwifery
September 10-11,2018 Prague,Czech Republic

Vigo Oller O, Leyva Moral J.M, Feijoo Cid M, Bernabeu Tamayo, M D, Martin Royo J, Galbany Estragues , Fernandez Vandellos P

Vigo Oller, O - Institut Catala de la Salut. Generalitat de Catalunya. Leyva-Moral, JM - Universidad Autonoma de Barcelona, Department of Nursing. Faculty of Medicine Feijoo Cid, M - Universidad Autonoma de Barcelona, Department of Nursing. Faculty of Medicine Bernabeu Tamayo, M D - Universidad Autonoma de Barcelona, Department of Nursing. Faculty of Medicine Martin Royo, J - Institut Catala de la Salut. Generalitat de Catalunya Galbany Estragues, P - Universidad Autonoma de Barcelona, Department of Nursing. Faculty of Medicine Fernandez Vandellos, P ΓΆΒ?Β? IDIBAPS, CIBERES. Barcelona, Spain

Posters & Accepted Abstracts: J Nurs Health Stud

DOI: 10.21767/2574-2825-C4-012

Abstract

Background: Standardized Nursing Terminologies apprise the nursing care provided and facilitate clinical research and education. Aim: To identify strengths and weaknesses of standardized nursing terminologies used in electronic health records. Methods: A literature review was conducted. Studies were retrieved from: PubMed, Cochrane Library, CINAHL, Cuiden, Scopus, and ISI Web of Knowledge. The search strategy included articles in English, French, Portuguese and Spanish published between 2002 and 2016 focusing on standardized nursing terminologies most frequently used in electronic nursing records. Findings: NANDA/NIC/NOC and ICNP were the Standardized Nursing Terminology most frequently used. The use of Standardized Nursing Terminology allows to make comparisons between nursing records sharing the same terminologies. Sometimes the standard terminology was not sufficiently understood by nurses and therefore it could not be efficiently used, at some extent, hindering nursing continuity care. Discussion: Standardized nursing terminologies had a strong impact on information quality, process quality and efficiency, but not on patients or professionals. Conclusion: nurses must know why they are using a particular standardized terminology is beneficial or detrimental for patients, nursing knowledge or for themselves.

Biography

Mrs Olga Vigo Oller is presently working at Catalan Health Institute. Government of Catalonia, Spain.

E-mail: ovigo@gencat.cat