Promoting Safe Nursing Care by Bringing Visibility to the Disciplinary Aspects of Interdisciplinary Care

The provision of safe and effective interdisciplinary care requires making the unique and interdependent aspects of disciplinary care visible and understandable. Ideally, the electronic health record (EHR) should capture both disciplinary and interdisciplinary care. This paper reports on a "real time" pilot of a technology supported method of documenting, communicating, and tracking the nursing component of the patient's plan of care for eventual integration into EHR. An intensive care unit tested the intervention that included the adoption and use of the NANDA, NOC, and NIC terminologies. Multiple methods were used to evaluate the impact of the care planning method for a 12 month period. We found that the increased visibility of nursing care promoted greater awareness and understanding (collective mind) of care and in turn enhanced continuity. The results of the pilot were used to further refine our theoretical framework and method for the multi-site study currently underway.

[1]  G Coldwell,et al.  Just for the record. , 1996, Nursing management.

[2]  E. Beard,et al.  American Association of Colleges of Nursing. , 2002, JONA'S healthcare law, ethics and regulation.

[3]  John Seely Brown,et al.  The Social Life of Documents , 1996, First Monday.

[4]  C M Kerr,et al.  Factors influencing the documentation of care. , 2000, Professional nurse.

[5]  J Webster The effect of care planning on quality of patient care. , 1998, Professional nurse.

[6]  S. Moorhead Nursing outcomes classification (NOC) , 2000 .

[7]  C. Patterson Joint Commission on Accreditation of Healthcare Organizations , 1995, Infection Control & Hospital Epidemiology.

[8]  Sharie Falan,et al.  Establishing competency in the use of North American Nursing Diagnosis Association, Nursing Outcomes Classification, and Nursing Interventions Classification terminology. , 2003, Journal of nursing measurement.

[9]  Anne Frølich,et al.  Evaluating two different methods of documenting care plans in medical records , 2003 .

[10]  JULIA R. STOCKER,et al.  The HANDS Project: Studying and Refining the Automated Collection of a Cross-setting Clinical Data Set , 2002, Computers, informatics, nursing : CIN.

[11]  Christian Heath,et al.  Documents and professional practice: “bad” organisational reasons for “good” clinical records , 1996, CSCW '96.

[12]  Phyllisis Mei-Mei Ngin,et al.  Organizational analyses of computer user acceptance among nurses , 1993 .

[13]  Dochterman,et al.  Nursing interventions classification (NIC). , 1992, Medinfo. MEDINFO.