Representing Nursing Practice in EMR/EHRs.

ABSTRACT

OBJECTIVE: Review of the ISO 18104 technical standard for a Nursing Categorial structure to best represent nursing practice in EMR/EHRs and digital health ecosystems. METHODS: Application of ISO standard review guidelines in consultation with ISO member stakeholders. RESULTS: Comprehensive views of the nursing practice knowledge domain are presented as mindmaps. Groups of patients can now be identified using the 'type of subject of care' category. The collaborative role of nurses is now recognized. This high level structured information model recognises nursing diagnosis, nursing actions and nurse sensitive outcomes relative to other categories and sub-categories known to influence nursing actions and nurse sensitive outcomes. DISCUSSION: This nursing practice framework reflects the nursing process. It supports conceptual and logical analysis of patient journey related nursing practice. CONCLUSION: This updated categorial structure is a good fit with today's information technologies. Its adoption enables the value of nursing services provided to be demonstrated.