Implementing Oncologic Nursing Care Plans in Electronic Health Records With Two Taxonomies: A Pilot Study.

Abstract

Background: Nursing care plans document the nursing process, displaying actions, and illustrating expected outcomes. Their integration into electronic health records (EHRs) is critical for accurate documentation, enhanced by standardized nursing terminologies that promote communication, critical reasoning, and patient safety through consistent language for information.

Objective: This study aimed to identify appropriate standardized nursing terminology tailored to the context of a Northern Italian Cancer Center and research facility for developing nursing care plans and starting their integration into institutional EHRs.

Methods: Participatory action research was conducted to select proper terminology respecting the oncological setting, develop nursing care plans, and start their implementation in EHRs. The nursing team of a pilot ward collaborated closely with the researchers as coresearchers. Care plan samples were presented using the North American Nursing Diagnosis Association-International Nursing Intervention Classification, Nursing Outcomes Classification, and International Classification for Nursing Practice (ICNP) in the test section of the EHRs to gather nurses' preferences. Quantitative data collection, focus groups, and survey analyses were conducted.

Results: Nurses chose the ICNP for its flexibility but sought better methods to define patient severity in assessments and outcomes. They suggested incorporating the Common Terminology Criteria for Adverse Events to enable context-sensitive care plans.

Conclusions: End-user involvement is essential for developing EHRs, enhancing system usability, and reducing implementation resistance. Including nurses in management decisions empowers them, and improves care quality.