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Specifically designed for clinical information systems, the CCC facilitates nursing documentation at the point-of-care. The CCC was developed empirically through the examination of approximately 40,000 textual phrases representing nursing diagnoses/patient problems, and 72,000 phrases depicting patient care services and/or actions.
It is vital that a recognized nursing assessment framework is used in practice to identify the patient's* problems, risks and outcomes for enhancing health. The use of an evidence-based nursing framework such as Gordon's Functional Health Pattern Assessment should guide assessments that support nurses in determination of NANDA-I nursing diagnoses.
A nursing diagnosis may be part of the nursing process and is a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. Nursing diagnoses foster the nurse's independent practice (e.g., patient comfort or relief) compared to dependent interventions driven by physician ...
Electronic nursing documentation is an electronic format of nursing documentation an increasingly used by nurses. Electronic nursing documentation systems have been implemented in health care organizations to bring in the benefits of increasing access to more complete, accurate and up-to-date data and reducing redundancy, improving ...
The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes, and each with a label, a definition, and a set of indicators and measures to determine achievement of the nursing outcome and are included The terminology is an American Nurses' Association -recognized terminology, is ...
NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology, that was officially founded in 1982 and develops, researches, disseminates and refines the nomenclature, criteria, and taxonomy of nursing diagnosis. In 2002, NANDA became NANDA ...
Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot. Procedure classifications list procedure code, which are used to capture interventional data.
A computerised nursing care plan is a digital way of writing the care plan, compared to handwritten. Computerised nursing care plans are an essential element of the nursing process. [8] Computerised nursing care plans have increased documentation of signs and symptoms, associated factors and nursing interventions. [8]