Is there any regulatory mandate that patient problems, interventions and outcomes included in an EHR, should be stated using NANDA-I terminology?
NANDA International

There is no regulatory mandate; however NANDA International nursing diagnoses are strongly suggested by standards organizations for inclusion into the EHR. Several international expert papers and studies promote inclusion of the NANDA-I taxonomy into the EHR based on several reasons:
  • The safety of patients requires accurate documentation of health problems (e.g. risk states, actual diagnoses, health promotion diagnoses) and NANDA-I is the single classification having a broad literature base (with some diagnoses evidence-based including LOE formats). Most important - NANDA-I diagnoses are comprehensive concepts including related factors and defining characteristics. This is a major difference from other nursing terminologies.
  • NANDA-I concepts are included in SNOMED to assure data exchange and control.
  • NANDA-I, NIC and NOC (NNN) not only are the most frequently used classifications internationally; studies have shown these to be the most evidence-based and comprehensive classifications.
  • NANDA-I diagnoses and NIC/NOC are under continual refinement and development. These classifications are not single-author products – instead, they’re based on the work of professional nurses as members of NANDA International and at the University of Iowa Center for Nursing Classification and Clinical Effectiveness. A majority of NANDA-I members are Nursing Professors/ Educators, Nursing Informaticists, Nursing Researchers and Clinicians.
Related studies:
•Anderson, C. A., Keenan, G., & Jones, J. (2009). Using bibliometrics to support your selection of a nursing terminology set. CIN: Computers, Informatics, Nursing, 27(2), 82-90.
•Bernhard-Just, A., Hillewerth, K., Holzer-Pruss, C., Paprotny, M., & Zimmermann Heinrich, H. (2009). Die elektronische Anwendung der NANDA-, NOC- und NIC - Klassifikationen und Folgerungen für die Pflegepraxis. Pflege, 22(6), 443-454.
•Keenan, G., Tschannen, D., & Wesley, M. L. (2008). Standardized nursing teminologies can transform practice. Jona, 38(3), 103-106.
•Lunney, M. (2006). NANDA diagnoses, NIC interventions, and NOC outcomes used in an electronic health record with elementary school children. Journal of School Nursing, 22(2), 94-101.
•Lunney, M. (2008). Critical Need to Address Accuracy of Nurses’ Diagnoses. OJIN: The Online Journal of Issues in Nursing, 13(1).
•Lunney, M., Delaney, C., Duffy, M., Moorhead, S., & Welton, J. (2005). Advocating for standardized nursing languages in electronic health records. Journal of Nursing Administration, 35(1), 1-3.
•Müller-Staub, M. (2007). Evaluation of the implementation of nursing diagnostics: A study on the use of nursing diagnoses, interventions and outcomes in nursing documentation. Wageningen: Ponsen & Looijen.
•Müller-Staub, M. (2009). Preparing nurses to use standardized nursing language in the electronic health record. Studies in health technology and informatics: Connecting Health and Humans, 146, 337-341.
•Müller-Staub, M., Lavin, M. A., Needham, I., & van Achterberg, T. (2007). Meeting the criteria of a nursing diagnosis classification: Evaluation of ICNP®, ICF, NANDA and ZEFP. International Journal of Nursing Studies, 44(5), 702-713.

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