Common Nursing Terminology for Clinical Information Systems

UNLABELLED The lack of professional agreement upon chosen terminology in nursing detracts from the role of Clinical Information Systems (CIS) as central repositories of patient health records. The purposes of this paper are: (1) Identification of common terminology for clinical nursing information in CHS according to the following stages: patient history of health and illnesses; nursing assessment; nursing interventions and outcomes. (2) Implementation of the common terminology into computerized applications in several nursing settings. The sample included 224 nurses divided into four groups. Each group was asked to identify the common initial data for patient history and nursing interventions, based on professional experience, expertise, clinical standards and organizational / legal policy. The identification of nursing assessments and outcomes was done according to evidenced-based Clinical Guide-Lines (CGL) for each nursing setting. The CGL were chosen as a source for assessment and outcome classification for two main reasons. First, the CGL include criteria of the clinical state by the degree of severity base, which are acceptable and comprehensible to other disciplines within the healthcare system. Second, the lack of evidence-based researches related to clinical nursing outcomes. RESULTS Standard patient history of health and illnesses (admission and discharge) was developed for all departments in the hospital with flexibility to add any specific clinical data upon requirement. A total of 62 nursing assessments / outcomes were identified from the CGL in the four chosen nursing settings. 43 (70%) nursing assessments / outcomes were common both for nursing practice in hospitals and community clinics. 30 (40%) were implemented in the community clinics CIS application, 19 (31%) in the oncology CIS application, and 16 (26%) in the delivery CIS application. The groups identified a total of 70 nursing interventions. 49 (70%) nursing interventions were common both for nursing practice in hospitals and community clinics. 59 (84%) were implemented in the community clinics CIS application, 18 (26%) in the oncology CIS application, and 29 (41%) in the delivery CIS application. For summary, the definition process, including computerization, spread across four years. The community CIS application serves about 1500 clinics in CHS Israel (which employs about 2500 nurses). The admission and discharge CIS application serves 7 general hospitals, and is currently implemented in the internal and surgical departments (about 30 departments, 35 average beds each). The oncology CIS application is implemented in two oncology centers, and the delivery CIS application will soon be implemented in 8 hospitals.