The nurse is accessing information about standard classification of terms prior to documenting in a client's computerized clinical record. Which systems should the nurse consider using for this documentation?

Question

1. ANA
2. HIPAA
3. NANDA
4. The Omaha system
5. HHCC
6. NOC

Answer 1

Correct Answer: 3, 4, 5, 6
Rationale 1: The ANA has a position statement on privacy, confidentiality of medical records, and the nurse's role, but it is not one of the classification systems used in the United States.
Rationale 2: HIPAA is a piece of legislation that addressed privacy of and access to health records.
Rationale 3: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has established guidelines for the use of nursing terminology by companies that are creating software programs for nursing application. In doing this, NIDSEC recognizes the classification systems that include North American Nursing Diagnosis Association (NANDA) taxonomy.
Rationale 4: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has established guidelines for the use of nursing terminology by companies that are creating software programs for nursing application. In doing this, NIDSEC recognizes the classification systems that include the Omaha System.
Rationale 5: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has established guidelines for the use of nursing terminology by companies that are creating software programs for nursing application. In doing this, NIDSEC recognizes the classification systems that include the Home Health Care Classification (HHCC).
Rationale 6: The ANA Nursing Information and Data Set Evaluation Center (NIDSEC) has established guidelines for the use of nursing terminology by companies that are creating software programs for nursing application. In doing this, NIDSEC recognizes the classification systems that include the Nursing Outcomes Classification (NOC).