Bedside nurses have been observed to perform caring interventions (CIs). Although interoperable nurse CIs exist in SNLs, how and whether nurses document CIs in EHRs is not established.
Using NIC-7th Classification, Clinical Care Classification and Italian Nomenclature of Nursing Care Performance, we aimed to:
1. Identify interoperable nursing terms that represent CIs that could be used in EHR.
2. Determine synonyms and related terms for CIs across the three classifications.
3. Identify gaps in the classifications related to interoperable documentation of CIs.
We conducted a descriptive study guided by Watson’s Human Caring Theory. We identified 45 interoperable nursing terms across the three classifications that could be used in EHR. The term mapped to 8 of Watson’s 10 Carative Processes. There were 18 synonyms, 16 terms that were closely related. Eleven terms were represented by only classification and only one Carative Process has a synonym across all three classifications.