Nursing terminology: documentation of quality outcomes.

Abstract

Recently, government and healthcare providers have recognized the tremendous value and importance of advancing the use of electronic healthcare information systems. Without question, the issue of quality has become a focus of concern for consumers, politicians and healthcare providers and a priority for healthcare organizations in the 21st century. The nursing profession through the American Nurses Association has long recognized the need for quantitative evidence to measure the relationship of documentation to the impact on patient care. The following article discusses the ability of electronic healthcare information systems to collect nursing data using nursing terminology for care quality and outcome management. The purpose is to inform informatics professionals of an immediate need to connect electronic healthcare information systems with a standard, concept-based, atomic-level, coded nursing terminology readily available in the public domain for the longitudinal analyses of the continuity of care and of the nurses' contribution to healthcare quality.