Which terminology system is specifically used for recording nursing diagnoses in electronic health records?

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The terminology system specifically used for recording nursing diagnoses in electronic health records is the North American Nursing Diagnosis Association (NANDA) International. NANDA provides a standardized classification of nursing diagnoses which allows nurses to identify patient problems in a clear and consistent manner. This is essential for effective communication among healthcare providers and enhances the quality of care by ensuring that nurses can document and monitor patient conditions accurately.

NANDA's diagnoses are critical for guiding nursing interventions and assessing patient outcomes, making it an integral part of nursing practice and documentation within electronic health records. It ensures that nursing diagnoses are widely understood and universally applied in clinical settings, thus supporting the continuity of care.

While other options mentioned, such as the Nursing Interventions Classification (NIC) and Omaha System, serve vital roles in nursing practice (focusing on interventions and comprehensive care, respectively), they do not specifically address the nomenclature for nursing diagnoses. The Perioperative Nursing Data Set (PNDS) also targets a specific practice area and does not encompass the broader range of nursing diagnoses as covered by NANDA. Thus, understanding and utilizing NANDA International is crucial for accurately recording nursing diagnoses in electronic health records.

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