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

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 the status of their patient's nursing care needs. They noted less agreement with statements of the care plan offering information on assessment of patient outcomes of nursing care.

CONCLUSIONS.  The patient plan of care in the electronic record is expected to offer nurses the ability to communicate the needs of the patient and assess outcomes of care. The survey findings indicate weaknesses warranting further exploration to identify changes needed to improve care planning documentation.