Ch. 15 Yoost

Computerized decision support systems (DSSs), sometimes called clinical decision support systems, include safe practice alerts and reminders that improve the quality of care. Some DSSs assist in determining a correct diagnosis and choosing an appropriate medication. Access to needed information at the point of care supports evidence-based practice initiatives.

Computerized provider order entry (CPOE) allows orders to be directly communicated to the appropriate department—diet orders to dietary, medication orders to the pharmacy, laboratory orders to the laboratory. Elimination of an intermediary for order transcription decreases the potential for errors related to the ambiguity of handwritten orders and allows quicker responses by appropriate departments. Legibility and availability of computerized documentation improve provider communication. The Agency for Healthcare Research and Quality (AHRQ) recommends CPOE as one of the safe practices for better health care. CPOE systems ensure legible orders and have the potential to reduce ordering and transcribing errors. Disadvantages of CPOE include workflow issues, ability to bypass safety features, provider resistance to new technology, use of nonstandard terminology, and overdependence on technology.

Computerized clinical decision support systems (CDSSs) are usually paired with CPOE. When used with a CPOE system, the CDSS suggests dosages, frequencies, and routes of administration for drugs; cross-checks for drug allergies and drug–drug interactions; and may suggest laboratory tests, depending on the drugs ordered. When too many alerts and warnings are used in a CDSS, the user may ignore them and put patient safety at risk (AHRQ, 2019).

Record Management

Implementation of computerized or electronic medical records makes patient records readily available through remote access to multiple providers at the same time. This availability of patient information supports efficient delivery of effective care. 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 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, DSSs, and online clinical reminders and alerts. Because nurses have access to drug formularies and the National Library of Medicine, the latest literature on a specific medical problem or medication is readily available.

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 (Werley & Lang, 1988). Standardized collection of data in nursing documents what nurses do and provides the basis for funding of nursing care. The NMDS facilitates accurate documentation to maintain quality and safety in patient care (Håkonsen, Pedersen, Bjerrum, et al., 2018).

Implementation of a standardized nursing terminology has made a significant impact on patient outcomes. McCormick, et al. (2015) describe how standardized terminology in nursing can be achieved through comparable, sharable, quality data based on evidence. There are specific standardized nursing terminologies and multidisciplinary terminologies—such as SNOMED CT (Systematic Nomenclature of Medicine Clinical Terms)—that support nursing practice. SNOMED CT is a coding system, controlled vocabulary, classification system, and thesaurus, designed to capture information about a patient’s history, illnesses, treatment, and outcomes. The use of a standardized nursing terminology provides visibility to the nursing profession and documents the value of professional nursing.

A patient’s EHR is based on information in the NMDS. The nursing diagnoses, interventions, and outcomes use standardized nursing terminology. Standardized nursing diagnoses taxonomies are also available from the International Council of Nurses’ (ICN) International Classification for Nursing Practice (ICNP) and NANDA International (NANDA-I). More information about these taxonomies is available in Chapters 5 and 7. The ICNP contains standardized outcomes and interventions. Nursing Outcomes Classifications (NOCs) contains measurable patient outcomes. Nursing Interventions Classifications (NICs) provide standardized nursing interventions. See Chapters 5, 8, and 9 for more information about standardized outcomes and interventions. Each nurse reading and documenting in the EHR understands the diagnosis and can provide the interventions and measure the outcomes. Use of multidisciplinary terminologies aids interprofessional health care team members in understanding each other when communicating about a patient.

The ICNP is a standard terminology that provides a dictionary to describe and report nursing practice in a systematic way. This information supports care and decision-making to inform nursing education, research, and health policy (ICN, 2019). The ICNP is now included in SNOMED CT. The World Health Organization Family of International Classifications (WHO-FIC) accepted ICNP as a related terminology in 2008.

Other standardized terminologies are available for specialized settings. The Perioperative Nursing Data Set (PNDS) provides terminology standardized for the perioperative nurse. The Nursing Management Minimum Data Set (NMMDS) is used by nurse managers.