The informatics nurse is charged with identifying a terminology system that can be used to document the elements of the nursing process within the care plan. Which system should the nurse recommend?
A) The Omaha System
B) The PeriOperative Nursing Data Set (PNDS)
C) Personal health record
D) NANDA-I
D) NANDA-I
Explanation: A) The Omaha System is a problem classification scheme that identifies signs and symptoms, clinical findings, intervention scheme interventions, and procedures.
B) PNDS, developed by the Association of periOperative Registered Nurses (AORN), is a standardized perioperative nursing vocabulary that provides nurses a clear, precise, and universal language for clinical problems and surgical treatments.
C) The personal health record is not identified as a system to document the elements of the nursing process within the care plan.
D) NANDA-I is used to document nursing diagnoses within all settings and across the care continuum. The coding system can be used within the electronic health record. NANDA-I has been linked to the NIC interventions and NOC outcomes.
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