Standardized Nursing Terminologies and Electronic Health Records: A Secondary Analysis of a Systematic Review

Background/Objectives: Standardized nursing terminologies (SNTs) have been associated with improved patient and organizational outcomes. This secondary analysis aims to examine how structured nursing assessment data and documentation are integrated into electronic health records (EHRs) in studies that report on the impact of American Nurses Association–recognized SNTs. Methods: Data were extracted from all 53 primary studies included in a previously published systematic review. The original literature search was conducted in PubMed, Scopus, CINAHL, and OpenGrey. Extracted data focused on nursing assessment tools, use of EHRs, inter-rater reliability, and methodological characteristics. Results: Gordon’s Eleven Functional Health Patterns was the most frequently used nursing assessment framework, often in combination with NANDA-I diagnoses. However, details regarding assessment tools and their application in EHRs were inconsistently reported. Only about one-third of the studies explicitly indicated the use of EHRs, though an upward trend in their use has been observed over the last decade. Inter-rater reliability was reported in a limited number of studies, with considerable variation. An overall increasing trend in the use of nursing assessment data in electronic health records was observed over the past decade. Conclusions: The integration of SNTs with structured assessment frameworks into EHRs is increasing but remains inconsistently reported. Standardized documentation practices could strengthen nursing visibility, support quality improvement, and enhance outcome measurement in both clinical and research contexts.