The Value of Nursing Diagnosis inElectronic Health Records (EHR)

Chapter Four

The Value of Nursing Diagnosis inElectronic Health Records (EHR):

A Guideline for Educators

ContributorsMatthias Odenbreit

Jane M. Brokel

• The Use of Nursing Diagnoses within the Electronic Health Record (EHR)

• Features of the Digital Record

• The Importance of Using Nursing Diagnoses and Documentation

Learning Topics

• How to Develop and Improve the Functions, Features and Information in an EHR

• Clinical Decision-Making Applications

• The Concept of Electronic Health Records

• Nursing Diagnoses in Longitudinal EHRs

• Interpreting Information

Learning Topics

• Developing Functions of the EHR

• Knowing How to Guide the Nursing Decision Process to Find Accurate Nursing Diagnoses

Learning Topics

• Demonstrate to Students the Use of EHRs

• Give Graduate Students Overview of Nursing Informatics and Nursing Classifications

Faculty Guide

Nursing Diagnoses in the EHR

• Skills to Document Nursing Diagnoses in the Most Appropriate Location in the EHR

• Technologies that Provide Opportunities to Document for the Patient’s Long-Term Health Needs

• Overcoming the Gaps within Current Technologies and Fostering Improvements

Faculty Guide

Foster Students’ Knowledge About

• The Use of CDS Interventions Available in EHR to Facilitate a Nurse’s Decision-Making Process

• Prioritizing Nursing Diagnoses

• Measuring Patient Outcomes

Faculty Guide

Foster Student’s Knowledge About

• Use Sources Like Interviews, Physical Examination, Ongoing Observations and Compiling from Historical Documents

• Teach Documenting of Nursing Diagnoses with the Rationale for Decision

Faculty Guide

To Enhance Students’ Knowledge About Nursing Assessments

• Describe Assessment Frameworks

• Demonstrate How to Find Important Data

• Let Students Explore Different Settings and Frameworks

• Help Students and Novice Nurses and Faculty to Handle the Variation in EHRs

Faculty Guide

To Enhance Students’ Knowledge About the Use of EHRs

• Showcase the Taxonomy for Nursing Practice

• Provide Knowledge of All the Domains of the Nursing Taxonomy

• Increase the Student’s Holistic Approach to Assess the Patient’s Human Responses

Faculty Guide

Guiding Student Learning

• Knowledge Resources

• Problem List

• Clinical Decision Support (CDS)

Faculty Guide

Guiding Student Learning

• Interdisciplinary Care Planning

• Health Information Exchange

• Personal Health Records

Faculty Guide

Guiding Student Learning