Learning Objective 1: The learner will be able to understand the most frequent nursing diagnoses, interventions, outcomes in different oncology units.
Learning Objective 2: The learner will be able to understand the advantages of electronic documented nursing diagnoses, interventions, outcomes in practice and research.
The study aimed to explore nursing care (problems, interventions, outcomes) as documented by nurses using standardized terminology in electronic health records for oncology care. We also examined the outcome change scores for the frequent problems. Findings provided resources for continuing education for nurses, managers and administrators.
Donabedian’s structure-process-outcome is the framework for this study. In this descriptive retrospective study, we included patients with cancer admitted in four oncology units in a tertiary hospital over seven months. Data collection included demographics, diagnoses, interventions, and outcomes. Data were retrieved from medical records, and the nursing documentation system. Only patients with planned nursing care documented were analyzed.
The sample (2,237) was primary female (63%) and white (89%). The most common elements in nursing care were diagnosis (Acute Pain), intervention (Pain Management), and outcome (Pain Level). Patients with Acute Pain rated their outcome scores from 1 to 5 for Pain Level. We compared the first and last scores and found most patients (39%) kept the same scores at discharge, and 35% of them improved the score by 1. The priorities of planned nursing care differed by unit and length of stay. We also found that patient safety, such as Fall Prevention, was common among the top ten concerns in the study.
The use of electronic standardized terminologies for nursing care benefits the exploration of common problems, interventions, and outcomes, and in monitoring the change in their scores in an efficient and systematical way in clinical practice and research. This assists nurses in managing oncology patient care for individualized care, decision making and time management. The link between electronic standardized terminologies used for nursing care and other elements of study interests in the electronic health records provides potential benefits for future research.