Journal of the American Academy of Nurse Practitioners
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J Am Acad Nurse Pract · Jul 2012
Randomized Controlled TrialIdentifying the barriers to use of standardized nursing language in the electronic health record by the ambulatory care nurse practitioner.
This 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). ⋯ Respondents 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.