Defining and incorporating basic nursing care actions into the electronic health record

Journal of Nursing Scholarship : an Official Publication of Sigma Theta Tau International Honor Society of Nursing
Jane EnglebrightCathy R Taylor

Abstract

To develop a definition of basic nursing care for the hospitalized adult patient and drive uptake of that definition through the implementation of an electronic health record. A team of direct care nurses, assisted by subject matter experts, analyzed nursing theory and regulatory requirements related to basic nursing care. The resulting list of activities was coded using the Clinical Care Classification (CCC) system and incorporated into the electronic health record system of a 170-bed community hospital. Nine basic nursing care activities were identified as a result of analyzing nursing theory and regulatory requirements in the framework of a hypothetical "well" patient. One additional basic nursing care activity was identified following the pilot implementation in the electronic health record. The pilot hospital has successfully passed a post-implementation regulatory review with no recommendations related to the documentation of basic patient care. This project demonstrated that it is possible to define the concept of basic nursing care and to distinguish it from the interdisciplinary, problem-focused plan of care. The use of the electronic health record can help clarify, document, and communicate basic care elements and imp...Continue Reading

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Citations

Feb 6, 2015·Journal of Obstetric, Gynecologic, and Neonatal Nursing : JOGNN·Catherine H Ivory
Mar 8, 2018·Journal of Clinical Nursing·Rebecca FeoTiffany Conroy
Dec 27, 2017·Journal of Clinical Nursing·Rebecca FeoAlison Kitson
Feb 6, 2018·Journal of Clinical Nursing·Sandra M G ZwakhalenMarieke J Schuurmans
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Apr 16, 2016·Computers, Informatics, Nursing : CIN·Catherine H Ivory
Aug 24, 2020·Research in Nursing & Health·Carolien C J M M VerstratenJanneke M de Man-van Ginkel

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