Automation of nursing documentation in client records is one of today's formidable challenges in healthcare settings. Some stakeholders view standardized nursing language as a fundamental component of an automated record, with the end goal of generating valid, reliable data on nursing services and client outcomes. However, few successful applications of standardized nursing language for practice standards and data generation exist in the literature. A joint practice-and-data quality project based on standardized nursing language in an automated platform was undertaken by four local public health departments. Outcomes of this project included articulation of standards for nursing practice and creation and implementation of a sound data quality infrastructure for nursing documentation of client assessments, service delivery information, and client outcomes.
- Omaha System
- Quality improvement