Which terminology system would the nurse use to enter nursing diagnoses interventions and outcomes in electronic health records quizlet?

D. International Classification for National Practice (ICNP)

The ICNP was developed under the auspices of the International Council of Nurses (ICN). It addresses nursing phenomena, actions, and outcomes. It contains descriptions and comparisons of nursing practices locally, regionally, nationally, and internationally. It articulates the contributions of nursing to health and health care, enhances communications, and improves the quality and continuity of health care on a global basis. The CCC is a nursing terminology system that is used for documenting the plan of care in a health care setting. It includes documented information about the diagnosis, the plan for nursing interventions, and the effectiveness of the outcomes. The PNDS is a set of nursing terminologies approved by the ANA for diagnoses, interventions, and outcomes for use in the perioperative area. The NIC is used in the planning phase of the nursing process to document specific nursing interventions for a patient.

C. Nursing informatics

Nursing informatics is the use of information, data, and technology to communicate, manage knowledge, mitigate errors, and support decision making. It requires knowledge, skills, and attitudes from the nurse to be able to effectively use information and technology. Nursing informatics is focused on the organization, analysis, and dissemination of information. Integrated delivery systems, health care patient systems, and computerized nursing networks do not use information and technology to communicate, locate and use knowledge, or reduce and eliminate errors.

C. Technical

Technical competency in informatics indicates the ability to use computers and technological equipment, software programs for word processing, and spreadsheets, along with competency in database development. The nurse with technical competency is also capable of making presentations, referring to websites, and sending e-mails. Utility competency addresses critical thinking and evidence-based practice applications. Nursing informatics specialists are experts who train others, supervise the use of information systems, and design systems for use by nurses. Leadership competency addresses ethical and management issues related to the use of information technology in nursing practice, education, research, and administration.

ANS: A, B, E
A standardized nursing terminology is a structured vocabulary that provides a common means of communication among nurses. A standardized language ensures that when a nurse talks about a specific patient problem, another nurse fully understands the problem. An example is the choice between pressure ulcer, decubitus ulcer, and bedsore. Do all nurses in all settings have a shared understanding of these labels for a patient problem? The Nursing Minimum Data Set (NMDS) represents the first attempt to standardize the collection of essential nursing data. These core data, used on a regular basis by most nurses in the delivery of care across settings, provide accurate descriptions of the nursing diagnoses, nursing care, outcomes of care, and nursing resources used. Collected on an ongoing basis, the NMDS enables nurses to compare data across populations, settings, geographic areas, and time. The International Classification for Nursing Practice (ICNP), developed under the auspices of the International Council of Nurses (ICN), provides a standard that facilitates the description and comparison of nursing practice locally, regionally, nationally, and internationally.

ANS: A, C, D, E
The Technology Informatics Guiding Education Reform (TIGER) initiative (2012) identified a set of skills needed by all nurses practicing in the 21st century. The TIGER Vision Pillars include management and leadership, education, communication and collaboration, informatics design, and IT policy and culture. This skill set includes informatics competencies that range from basic computer skills to advanced-level IT and literacy competencies and expertise. TIGER's vision for the future of nursing addresses informatics and emerging technologies to provide safer, patient-centered care by using evidence and technology in practice, education, and research. After meeting the educational and experience requirements, the nurse can receive certification in nursing informatics from the Health Care Information and Management Systems Society (HIMSS) and through the American Nurses Credentialing Center (ANCC). However, certification is not one of TIGER's Vision Pillars.

ANS: A
One classification system for nursing informatics competencies uses technical, utility, and leadership categories. Leadership competencies address the ethical and management issues related to using IT in nursing practice, education, research, and administration. Specific leadership competencies include the application of accountability, maintenance of privacy and confidentiality, and quality assurance. Technical competencies pertain to the use of computers and other technological equipment and the use of a variety of software programs for word processing, spreadsheet and database development, presentation, referencing, and e-mail. Utility competencies address critical thinking and evidence-based practice applications. Nurses who have a utility competency recognize the relevance of nursing data for improving practice and can access multiple information sources for gathering evidence for clinical decision making.

ANS: C
After meeting the educational and experience requirements, the nurse can receive certification in nursing informatics from the Health Care Information and Management Systems Society (HIMSS) and through the American Nurses Credentialing Center (ANCC). Technical competencies pertain to the use of computers and other technological equipment and the use of a variety of software programs for word processing, spreadsheet and database development, presentation, referencing, and e-mail. Utility competencies address critical thinking and evidence-based practice applications. Nurses who have a utility competency recognize the relevance of nursing data for improving practice and can access multiple information sources for gathering evidence for clinical decision making. Leadership competencies address the ethical and management issues related to using IT in nursing practice, education, research, and administration. Specific leadership competencies include the application of accountability, maintenance of privacy and confidentiality, and quality assurance. Technical, utility, and leadership competencies can be achieved without certification.

ANS: B
Descriptions of nursing informatics competencies often focus on levels that include beginner, experienced, specialist, and innovator. Beginner skills include computer, information, and web literacy; fundamental skills in information management and computer technology; and the ability to identify and collect relevant data. The nurse at the beginning level may have keyboarding skills, can document in the EHR, and look up medications and other health information on reputable Internet reference sites. The nurse at the experienced level of informatics competencies is able to see data relationships and make judgments based on trends and patterns in data, is skilled in information management and the use of computer technology, and is able to suggest areas for IT system improvement. The nurse at the specialist level of competency focuses on information needs for the practice of nursing; integrates and applies information science, computer science, and nursing science; and applies skills in critical thinking, data management, processing, and system development. At the specialist level of competency, the nurse may conduct research based on information trends or patient data, devise applications for computer technology in nursing, or develop new software to enhance nursing care. Nursing informatics innovators conduct research and generate theory. They develop solutions and understand the interdependence of systems, disciplines, and outcomes.

ANS: A
The electronic medical record (EMR), which is the documentation of a single episode of care (i.e., outpatient visit or inpatient stay), becomes a part of the electronic health record (EHR), which is a longitudinal record of care. EHRs are becoming widely used for individual health care encounters and for maintaining patients' health records over long periods. As EHRs become fully implemented, they include provider order entries, progress notes for all disciplines, computerized medication profiles, access to diagnostic test results on a timely basis, decision support systems, and online clinical reminders and alerts.

ANS: B
Patient data collected by a nurse and recorded electronically are immediately available to all members of the health care team. The computerization of nursing practice data enables capture, storage, retrieval, organization, processing, and analysis of information. The information can be used to make a diagnosis, plan for care, provide nursing decision support, enhance documentation, and identify nursing care trends and costs. Systems that support data collection at the point of care can directly enhance patient care by decreasing the time spent on documentation, reducing the potential for errors, and supporting improved assessment and data communication. Computers, tablets, or pocket devices used at the bedside for documentation are examples of point-of-care technology.

ANS: B

A standardized nursing terminology is a structured vocabulary that provides a common means of communication among nurses. A standardized language ensures that when a nurse talks about a specific patient problem, another nurse fully understands the problem. Standardized nursing terminologies recognized by the American Nurses Association include NMDS (nursing minimum data set), NMMDS (nursing minimum data set), CCC (clinical care classification), ICNP (international classification of nursing practice), NANDA-I (NANDA International), NIC (nursing interventions classification), NOC (nursing outcomes classification), Omaha System, and PNDS (perioperative nursing data set). ABC and SNOMED CT are examples of multidisciplinary terminologies. ICD-9 details terminology for billing and coding, not nursing.

Which terminology system would the nurse use to enter nursing diagnoses intervention and outcomes in electronic health records?

What terminology does the nurse use to enter nursing diagnosis?

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