Program, Practice, and Vision: Standardized Nursing Language and the Computerized Patient Record

Abstract

BACKGROUNDIn 1997, the community‐based Nurse Case Management program of Aurora Health Care in Milwaukee, WI, was created to coordinate care for highrisk clients. Advanced practice nurse case managers partner with clients, families, and providers to establish goals and support efficient and effective use of healthcare resources. Clients referred to the program have evidence of suboptimal self‐management, complex health conditions, multiple specialty providers, or a history of high or inappropriate service utilization. Clients are typically seen in their homes, medical clinics, outpatient or other community sites.MAIN CONTENT POINTSFrom the start, the program was designed to provide coordinated care across the entire care continuum. Access to patient encounters, clinical, and financial data was identified as an essential component to providing and evaluating individual and program outcomes. The staff also needed a way to input data into the system. The program director was able to justify educational and information system support for the creation of a program‐specific documentation program. She valued the use of standardized nursing language as a way to capture and retrieve data about the discipline‐specific aspects of care. The NANDA, NIC, and NOC taxonomies were selected as the cornerstone for the nursing department of the largest Aurora hospital and the nurse case manager program. Administration further provided support for the department to partner with the established information system vendor in the creation of new software specifically designed to function within the integrated healthcare delivery system.The program was established based on the American Nurses Association standards for advanced practice and literature‐based best practice guidelines for patient care. Prior to implementation, the staff had basic computer access and limited standardized nursing language experience with NANDA diagnoses. The group set out to learn more about the NANDA/NIC/NOC taxonomies by attending a conference, using self‐study techniques from texts, and applying the concepts in their clinical practice. Several common patient problems and nursing interventions were recognized immediately. Sample plans with suggested NANDA/NIC/NOC linkages were developed for staff to use as a framework to tailor to the unique needs of their patients. Networking with colleagues provided an avenue to build confidence and consensus regarding taxonomy application.The documentation system was designed on paper and evolved into the program‐specific component of the systemwide computerized patient record. In addition to education, the staff invested much time in designing and developing expertise in computer use. Care Manager, the program‐specific software, went live in January 2000 and provided the case managers with a vehicle to access data, enter clinical notes and care plans, share data between providers, and track patient outcomes over time.CONCLUSIONSIt is important for users to have a clear vision of the functionality needed for practice. Significant educational and information system resources are needed. “Superusers” and focused education can increase the speed and efficiency of design and implementation processes.Because standardized nursing language is used to describe practice, staff members must develop expertise in using this terminology language to describe assessments, diagnoses, outcomes, and interventions in their daily practice. The next steps involve increasing system functionality to allow for more efficient documentation of assessments and interventions on the care plan and improve the ability to prescribe specific interventions within a NIC label. In regard to research, standardized nursing language provides a framework for descriptive and correlational studies that identify those interventions most effective in achieving best practice outcomes. Case managers need to use change theory to identify stage of readiness, appropriate NOCs to describe incremental change, and most effective NICs to promote patient movement toward action.