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Standardized Nursing Diagnoses in an Electronic Health Record: Nursing Survey Results

Nicolette A. Estrada, Candice R. Dunn · International Journal of Nursing Knowledge · 2012

PURPOSE.  A survey was conducted to obtain feedback from registered nurses as end-users of standardized nursing terminology for care planning in an electronic health record. Revisions to the care plan terminology were completed as part of an evidence-based project by nurses at one facility. METHODS.  The survey was conducted pre-, post-, and 2-year post-implementation to obtain feedback from the acute care registered nurses (RNs). FINDINGS.  Nurses reported a more positive agreement with the changes at 6 months compared with baseline, which generally was found to be sustained in the 2-year survey. Overall, the standardized terminology provided the nurses greater ease in their selection of nursing diagnoses and interventions in planning patient care, yet their reported satisfaction did not change. The survey identified several problematic areas related to nurses and care planning. Nurses reported less agreement with the statement about the care plans offering them the ability to determine

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