BACKGROUND. Chemical dependency (CD) documentation and nursing documentation within a hospital have differed in many ways. The organization's direction toward a multidisciplinary patient record using NANDA, NIC, and NOC standardized nursing languages (SNL) was a challenge for the CD counselors. The use of SNLs caused some discord with the counseling staff as to how a care plan could be individualized with the use of standardized language.
MAIN CONTENT POINTS. The CD counselors needed to resolve some issues before the change in documentation could proceed. The words “standardized language” provoked thoughts of “cookbook” care, so the counselors needed to reconcile the use of SNLs and the ability to develop individualized treatment plans. The counselors were initially uncertain about using nursing languages to describe their practice and the minimal counseling terms within the languages. These issues were overcome by studying the languages and seeing that they did address the practice of the CD counselors even though nursing developed the SNLs. Implementation included education about NANDA, NIC, and NOC. The staff needed time to accept the need for standardized languages to enhance interdisciplinary documentation and to remove the attitude barrier of “we've always done it this way.” The next step was to create and revise care plans and documentation screens.
CONCLUSIONS. The practice of providing care to patients in CD treatment is enhanced by using NANDA, NIC, and NOC because of the ability to develop a true interdisciplinary patient record, retain individualization of patient plans of care, use the outcomes to substantiate discharge status and recommendations, and assess effectiveness through use of outcome data. Pilot outcomes data indicate that CD counselors and nursing exhibit statistically significant results related to coping, decision making, knowledge: substance use control, leisure participation, psychosocial adjustment, life change, substance addiction consequences, self-esteem, and spiritual well-being. Future research efforts should include monitoring patient outcomes over the continuum of care. Most patients participate in an aftercare program following inpatient or outpatient treatment. It would be beneficial to follow outcomes throughout the entire course of a patient's treatment.
