Representing nursing judgements in the electronic health record

The naming of nursing phenomena and representing the phenomena in a standar dized manner suitable for encoding in computer-based systems is a challenge for the nursing profession at the national and the international level. Co nsiderable progress has been made in the development of classification syst ems for nursing practice. The focus of this article is on language systems developed to represent nursing judgements in computer-based systems, in par ticular the electronic health record. A review of two current systems and t heir proposed revisions (North American Nursing Diagnosis Association, NAND A, Taxonomies I and Ii, and the International Classification for Nursing Pr actice, ICNP, Alpha and Beta versions), according to the features suggested by the Computer-based Patient Record Institute (CPRI) for classification s ystems appropriate for implementation in computer-based systems, suggests t hat the evolving versions extend the current versions in terms of sufficien t granularity (depth and level of detail) and atomic and compositional char acter. However, it is not clear from the literature available to date wheth er the characteristics that are most closely related to definition of a for mal terminology (i.e. clear and nonredundant representation of concepts, sy ntax and grammar for logical constructions of compositional terms, synonyms and language independence) will be part of the evolving vocabularies. Form al terminology models and related tools have the potential to complement, e xtend, and refine existing nursing classification systems.