• Dianne Conrad, Patricia A Hanson, Susan M Hasenau, and Julia Stocker-Schneider.
• Kirkhof College of Nursing, Grand Valley State University, Grand Rapids, Michigan, USA. conraddi@gvsu.edu
• J Am Acad Nurse Pract. 2012 Jul 1; 24 (7): 443-51.

PurposeThis study identified the perceived user barriers to documentation of nursing practice utilizing standardized nursing language (SNL) in the electronic health record (EHR) by ambulatory care nurse practitioners (NPs).Data SourcesA researcher-developed survey was sent to a randomized sample of ambulatory care NPs in the United States who belonged to the American Academy of Nurse Practitioners (n= 1997).ConclusionsSurveyed ambulatory care NPs placed a higher value on documenting medical care versus nursing care. Only 17% of respondents currently use SNL and 30% believe that SNL is not important or appropriate to document NP practice. Barriers to using SNL in EHRs included lack of reimbursement for nursing documentation, lack of time to document, and lack of availability of SNL in electronic records.Implications For PracticeRespondents identified NP practice as a blend of medical as well as nursing care but NPs have not embraced the current SNLs as a vehicle to document the nursing component of their care, particularly in EHRs. Until these barriers are addressed and discreet data in the form of SNL are available and utilized in the EHR, the impact of the NPs care will be unidentifiable for outcomes reporting.©2012 The Author(s) Journal compilation ©2012 American Academy of Nurse Practitioners.

25 keywords...

hide…