We look at the process and progress of describing the work of nursing
because, as Lang has
stated, “If we cannot name it, we cannot control it,practice it, teach
it, finance it, or put it into public policy.” At first glance, nursing seems a
simple task. However, over many years, the profession has struggled, in part,
as a result of changes in healthcare delivery and financing, the expansion of
nursing’s role, and the dawning of the computer age. Gordon reminds us
that classification system development parallels knowledge development
in a discipline.2 As theory development and research have begun to define
nursing, it
has become necessary for nursing to find a common language to describe
what nursing is, what nursing does, and how to codify it. Thus, the terms
“classification
Systems” and “standardized language” were embraced, and the work
continues. Changes in the healthcare system occur at an ever-increasing rate.
One of these changes is the movement
toward a paperless (computerized or electronic) client record. The use
of electronic healthcare information systems is rapidly expanding, and the
focus has shifted from its original uses—financial and personnel management
functions—to the efficient documentation
of the client encounter, whether that is a single office visit or a
lengthy hospitalization. The move to
electronic documentation is being fueled by changes in healthcare
delivery and reimbursement as well as the growth of alternative healthcare
settings (outpatient surgeries, home health, rehabilitation or sub acute units,
extended or long-term care facilities, etc.), all of which increase the need
for a commonality of communication
Book Name
|
Nursing Diagnosis Manual (Planning, Individualizing,
and Documenting Client Care 4th Edition
|
Author
|
Marilynn E. Doenges, Marry Frances Moorhouse, Alice
C Murr
|
Language
|
English
|
Format
|
PDF
|
Size
|
107 MB
|
Pages
|
1034
|
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