Question

Which terminology system should the nurse use to enter nursing diagnoses, interventions, and outcomes in electronic health records?

1) Omaha system
2) Perioperative Nursing Data Set (PNDS)
3) Nursing Interventions Classification (NIC)
4) North American Nursing Diagnosis Association (NANDA) International

Answer 1

The North American Nursing Diagnosis Association (NANDA) International should be used by nurses to enter nursing diagnoses, interventions, and outcomes in electronic health records.

Step-by-step explanation:

The terminology system that a nurse should use to enter nursing diagnoses, interventions, and outcomes in electronic health records is the North American Nursing Diagnosis Association (NANDA) International. NANDA International provides a standardized classification of nursing diagnostic terminology for the assessment of patient outcomes and the development of nursing care plans, which is essential for documentation in electronic health records (EHR). Other systems, such as the Omaha system, are also used for documentation, but they are more specialized to certain fields or care settings. For instance, the Perioperative Nursing Data Set (PNDS) is specifically utilized in perioperative nursing.

The World Health Organization's International Classification of Diseases (ICD) is widely used in the clinical field to classify diseases and monitor morbidity and mortality. Though the ICD is useful for general medical diagnoses and billing, NANDA International's focus is on nursing diagnostics and care. The Centers for Disease Control and Prevention (CDC) also prioritize certain diseases as NPIs (notifiable priority diseases) and support their awareness, diagnostics, and treatment.