Electronic Health Record Analysis

APPLYING STANDARDIZED TERMINOLOGY
The evolution of the electronic health record (EHR) in current health care setting has fast-tracked the need in nursing to interconnect within the construct of the computer technology. The utilization of standardized terminologies within EHR is essential for nurses to delineate the influence of nursing care netted within the electronic record. Currently, healthcare is facing the challenges of mandatory regulations and standards which posits greater impact to nursing workforce to adopt to standardized terminology. It includes evidence-based clinical contents through plans of care, documenting care, clinical decision support to provide quality and safe care as well as financial incentive reporting requirement
NANDA-I nursing diagnosis in EHR provides nursing a framework to create problem lists and clinical pathways to identify patient condition plans of care. In the given scenario, the patient condition worsened that warrant admission to the critical care unit for close monitoring and aggressive treatment of decompensated Heart Failure (HF). Nursing diagnosis pertinent for the scenario were ineffective breathing pattern, excess fluid volume, fatigue, anxiety, sleeplessness, activity intolerance, impaired gas exchange are the common nursing diagnosis accounted for almost 50% of all nursing diagnosis among HF population (Park, 2014). In NANDA-I classification Ineffective breathing pattern is an actual diagnosis under domain 4: Activity/rest and under Class 4 Cardiovascular /Pulmonary responses. The study conducted by Park (2014) identified 10 interventions which accounted for 50% of those 143 NIC interventions were used. Identified nursing interventions are respiratory management like oxygen therapy, fluid and electrolyte management, teaching which includes, weight management, diet, exercise, medication, recognizing signs and symptoms of disease process itself, smoking/tobacco cessation assistance. Encourage family’s involvement in care and discharge planning and most especially transitions of care education. The use of NIC in EHR enables appropriate selection of research-based nursing interventions to show the impact of nursing by collaborating nursing interventions to other healthcare team. The NIC interventions are used in EHR through the implementation of plans of care, order sets and patient education. The NIC domains namely; physiological, behavioral, family, safety, health system and community can be use in all clinical setting especially HF