The evolution of a clinical database: from local to standardized clinical languages.

For more than twenty years, the University of Iowa Hospitals and Clinics Nursing Informatics (UIHC NI) has been developing a clinical database to support patient care planning and documentation in the INFORMM NIS (Information Network for Online Retrieval & Medical Management Nursing Information System). Beginning in 1992, the database content was revised to standardize orders and to incorporate the Standardized Nursing Languages (SNLs) of the North American Nursing Diagnosis Association (NANDA), Nursing Diagnosis Extension Classification (NDEC), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC). This paper reports the results of the database revision as well as recent usage data, new user selection methods for clinical content, and the advantages of a database utilizing SNLs.

Nursing Outcomes Classification: implications for nursing information systems and the computer-based patient record.

Quality improvement, measurement, and accountability pervade all health care, including the agendas of nursing, other care providers, and consumer groups. One new face of quality is unequivocal: data will be more equitably shared among all groups for data-based quality judgments. This will emphasize quality more than cost with greater involvement of the citizens compared to health care providers, payers, and health care product suppliers. Emphasis on quality will allow patients to have a voice heard and amplified through the implementation of patient-centered outcomes in the computerized patient care record. This article describes the implications of the Nursing Outcomes Classification (NOC) for nursing information systems and the computer-based patient record.

Evaluation of online documentation.

The University of Iowa Hospitals and Clinics (UIHC) implemented an online documentation system for patient care orders in 1994-1996. Developed entirely in-house, the INFORMM NIS (Information Network for Online Retrieval & Medical Management Nursing Information System) features order-generated task lists, defaulted charting responses, computer-generated chart forms, and graphical data displays. To measure the impact of automation on user perceptions, and documentation compliance, completeness, time, and location, a team of nursing and information systems representatives captured data before and after implementation. Staff surveys show more positive user perceptions. Documentation results indicate increased compliance and completeness, and a decrease or no change in time. Online documentation occurs mainly at unit workstations.

Nursing Interventions Classification implementation issues in five test sites.

The authors describe the implementation of the Nursing Interventions Classification (NIC), a standardized nursing language in five test sites: Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Genesis Medical Center, Davenport, Iowa; Loyola University Medical Center, Maywood, Illinois; Oaknoll Retirement Residence, Iowa City, Iowa; and The University of Iowa Hospitals and Clinics, Iowa City, Iowa. A description of NIC is provided along with a discussion of implementation issues and recommendations for implementation.

Nursing documentation in the computer-based patient record.

This paper describes the INFORMM NIS (Information Network for On-line Retrieval & Medical Management Nursing Information System) charting system developed by the Departments of Nursing and Information Systems at the University of Iowa Hospitals and Clinics (UIHC). The documentation system features automated work lists, defaulted charting responses, decision support, automatic computations, chart forms and reports, and graphical displays of clinical data. The impact of the on-line charting system has been demonstrated by content standardization with Nursing Interventions Classification (NIC), improved standards compliance, increased efficiency, enhanced timeliness, expanded accessibility, and an augmented data archive.

Implementation of standardized nursing languages (NIC, NOC) in on-line care planning and documentation.

At the University of Iowa Hospitals and Clinics (UIHC), the Standardized Nursing Languages (SNLs) of Nursing Interventions Classification (NIC) and Nursing-sensitive Outcomes Classification (NOC) are being implemented in on-line care planning and documentation. NIC and NOC are being integrated in the INFORMM NIS (Information Network For Retrieval & Medical Management Nursing Information System). The implementation process for SNLs includes six components: objectives, programming, database content, education, utilization, and evaluation. This process has been used successfully in NIC implementation and will be applied in NOC field testing.

On-line documentation of patient care orders.

The INFORMM NIS (Information Network For Online Retrieval & Medical Management Nursing Information System) provides on-line documentation of patient care orders. These orders, generated by the nurse or the physician, prescribe direct patient care and do not include interdepartmental orders such as laboratory, radiology, or pharmacy. The order charting functions support charting efficiency by defaulting previous responses so that the user enters only updates to earlier findings or new data. Available in tables maintained by NIS staff, charting responses provide decision support by suggesting valid results for each order. Using point-of-care devices, nursing staff chart patient data that are immediately available for review by all authorized members of the health care team. These data are printed automatically on computer-generated chart forms every twenty-four hours, but may be printed also on demand. Additionally, the patient data report, containing patient data entered on-line in the sixteen or twenty-four hours immediately preceding the print request, provides a summary that is useful for nurses' report and physicians' rounds.

The patient problem/nursing diagnosis form: a computer-generated chart document.

The INFORMM (Information Network for Online Retrieval & Medical Management) patient problem/nursing diagnosis form is a computer-generated, patient record document of information related to identified patient conditions and patient outcomes. These patient and nursing data, accessible online as well as in paper copy, enhance continuity of care by providing, to all authorized clinicians, a list and history of identified patient problems/nursing diagnoses and the patient's status in terms of the achievement of projected patient outcomes. This cumulative, patient-centered documentation facilitates patient care effectiveness and provides mechanisms to capture and retrieve patient and outcome data for quality improvement and research purposes.

Patient discharge referral: interdisciplinary collaboration.

The INFORMM (Information Network For Online Retrieval & Medical Management) patient discharge referral form is interdisciplinary in scope. The initial automated form, implemented on 41 general inpatient care units as of December, 1991, involved the collaboration of the departments of Nursing, Social Services, Medical Records, and Patient Registration. As development proceeds, it is expected that other clinical disciplines will contribute additional data and information to augment and complement the content of the patient discharge referral form.

Inductive methodology and a research team.

Large teams of researchers using inductive methodologies are relatively rare and present unique challenges to team members. A team from the University of Iowa reports on what it experienced during a project to develop a taxonomy of nursing interventions.