Assuring Nursing´s Voice in the Electronic Health Record

Language is essential as a mode of communication to preserve and transmit knowledge and culture. The distinct language of a profession gives meaning to terms and expressions as well as knowledge of needs and appropriate responses in a given situations. Since Nightingale´s direction to record observations, nurses have built their language to record purposes, experiences and meaning of their practice. Today, the nursing voice is missing in reporting software; it is difficult to record the caring essence of nursing within electronic health records. There is a need for research and development of software to communicate nursing that takes place during nurse-client and nurse-community health encounters. A team of university professors and graduate students in nursing and computer science has joined to generate nursing practice research data for use in creating and testing nursing language software. Data reflect the complexity of caring in nursing grounded in a distinctive community nursing practice model. The software is intended to complement other electronic health records, assuring the voice of nursing in reporting health care. This paper emphasizes identification of the problem and literature review. The work of the research team, the research approaches and initial results are included.