Vital Signs

The Nursing Interventions Classification, or NIC, is a standardized classification of interventions that nurses perform, used to standardize documentation, communicate care across settings, integrate data, support research, measure productivity, and design curricula. This post explains how NIC pairs with NANDA-I diagnoses and NOC outcomes, what a 32-study systematic review found, and how linkage work supports care planning in EHRs.

A drug interaction database is a collection of information on interactions between drugs, and it is the knowledge behind the alerts clinicians see when ordering or administering medications. This post explains how these databases are used, what a meta-analysis found about alert override rates near 90 percent, what experts recommend for alert design, and how on-demand checking compares with automatic alerts.

An ambulatory EHR is the electronic health record that supports clinics, physician offices, and other outpatient settings, with documentation, orders, results, and messaging. This post covers how it differs from inpatient systems, what national data show about adoption, and what studies of team-based documentation, AI scribes, and inbox use say about the time clinicians spend in the record.

NANDA Taxonomy II is a classification of nursing diagnostic concepts that names and codes the ways patients respond to health problems or life events. This post explains how the taxonomy supports care planning, how it links to the Nursing Interventions Classification and Nursing Outcomes Classification, and what recent studies show about education, label structure, and AI-generated nursing diagnoses.

Pharmacy informatics is the field that applies medication-related data, knowledge, and technology to improve medication management and safety. This post explains its scope, what systematic reviews found about barcode scanning, dispensing cabinets, and alert frequency, how pharmacists redesign autoverification and drug interaction alerts, and how nurses and pharmacy informaticists work together.

A clinical pathway is a structured, multidisciplinary care plan that translates guideline recommendations into steps of care for a specific condition or procedure. This post explains what pathways contain, what a 2025 Cochrane review of 58 studies found for complications and length of stay, how a hip replacement pathway performed, and how EHR tools and nurses support them.

The Omaha System is a research-based, standardized taxonomy for documenting client problems, interventions, and outcomes. This post explains its three components, why it is used in public health nursing and home visiting, what studies of Omaha System data have found about interventions and social determinants of health, and what informaticists should consider when building it into an EHR.

LWBS describes a patient who leaves a healthcare facility without being examined or treated. This post explains how LWBS is counted, what four recent studies found about who leaves and when, how it relates to crowding and equity, and how nurses and informaticists use triage workflow and data to reduce it.

A nursing information system is the part of the health information system that handles nursing documentation, especially maintenance of the nursing record. This post explains what it includes, how it relates to the EHR and to nursing terminologies, what recent studies found about near-misses, workarounds, and mobile systems, and how nurses and nurse informaticists shape it.

A licensed independent practitioner, or LIP, is a clinician permitted by law and by the organization to provide care without direction or supervision within the scope of the license and the privileges granted. This post explains how state law, medical staff credentialing, and hospital rules define the role, why the term matters for EHR order entry and security, and how one hospital used an LIP identifier to improve critical result communication.

The chief medical information officer, or CMIO, is the physician leader who guides how clinical information systems are developed, implemented, and improved, and who works with IT leaders to turn clinician needs into specifications. This post explains typical responsibilities, how the title relates to CCIO and CNIO, what the AMIA task force recommended on education and skills, and how nurses and CMIOs partner.

A standard operating procedure, or SOP, documents the established steps for carrying out a task or responding to a situation. This post explains how SOPs differ from policies and guidelines, what the HIPAA Security Rule and CLIA require to be written down, why downtime procedures are a classic informatics SOP, and how to keep procedures current, findable, and usable.

An adverse drug reaction is an unwanted response to a therapeutic drug. This post explains how ADRs differ from adverse drug events, how voluntary and mandatory FDA reporting works, what a scoping review found about barriers to reporting, how allergy and reaction documentation in the EHR supports safety, and the nurse’s role in recognizing and reporting reactions.

An addendum is new documentation that adds information to an original entry. It should be timely, dated, attributed, and explain why the information was added. This post explains how addenda differ from corrections, late entries, and patient-requested amendments, what CMS recordkeeping principles require, how EHR audit trails support them, and what nurses should do.

A problem-oriented medical record organizes health information around a list of the patient’s problems, so notes, orders, and results link to the problem they address. This post covers Lawrence Weed’s design, SOAP notes, the role of the EHR problem list, research on problem list accuracy and completeness, and what nurses and informaticists can do.

An encounter is an interaction between a patient and a practitioner responsible for assessing or treating the patient. In health IT it is the record unit that anchors clinical documentation, orders, billing, and quality data. This post explains encounter types, how registration creates encounters, common errors, and what nurses should know.

A point-of-care system is a clinical information system that uses bedside workstations, mobile devices, and connected equipment to capture and enter data where patients receive care. This post explains point-of-care documentation and technologies, their benefits for accuracy, timeliness, and safety, research on barriers and the nurse-patient relationship, point-of-care testing, and nursing roles.

The Nursing Minimum Data Set (NMDS) is a set of essential, uniformly defined nursing data elements developed to make nursing care visible and comparable across settings. This post explains the history and elements of the NMDS, the related Nursing Management Minimum Data Set, how standardized nursing data supports research, quality, and policy, and why it matters in modern EHRs.

An adverse drug event (ADE) is an injury resulting from the use of a medication, including adverse reactions, overdoses, and harm from medication errors. This post explains how ADEs differ from medication errors, common causes and high-risk drugs, how CPOE, barcode scanning, decision support, and pharmacy systems prevent ADEs, how they are detected and reported, and nursing roles.

Evidence-based medicine (EBM) is the conscientious use of the best available research evidence, integrated with clinical expertise and patient values, to make decisions about individual care. This post explains the steps of EBM, how evidence is ranked and appraised, how evidence-based practice applies in nursing, and how health IT helps bring evidence to the point of care.