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| (PCDS) Patient Care Data Set |
Throughout history, nurses have documented nursing care
using various methods. Consequently, there is a wide range of terms that describe
the same care (McCartney, 2011). As a result, a standardized nursing language have
been developed decades ago to be used as a common language, understood by all
nurses and describe nursing care (Rutherford, 2008). Standardized nursing language led to positive changes in the nursing world. Nurses from different
units, hospitals, or all around the globe can use commonly understood
terminology to identify specific problems, intervention and outcomes (O'Connor,
Hameister & Kershaw, 2000). Moreover, there are thirteen terminology sets
that had been approved by the American Nurses Association (ANA). One of these
sets is PCDS, which is retired. (PCDS) stands for patient care data set,
was developed by Judy Ozbolt along with members of the health system at the
University of Virginia in 1992. After that, Vanderbilt University medical
center tested PCDS for validity and reliability (Ozbolt, Fruchtnicht &
Hayden, 1994). The patient care data set is
a combination of terminologies that represent patient problems, care goals,
goal achievement status, and patient care orders. In addition, the data set
contains nursing diagnosis from NANDA, patient care activities and nursing
outcomes (Ozbolt, Fruchtnicht & Hayden, 1994). However, PCDS is
not a classification systems; it mainly serves as a set of terms to be used in
hospital’s acute care settings to capture and represent data in the patient
care information system. Further, PCDS
terms are organized into twenty-two components, and each component contains
three axes. These axes are problems, goals, and orders (Ozbolt,
Fruchtnicht & Hayden, 1994).
PCDS is used by nurses and
other health care providers, including physicians and health care workers in
acute care settings to plan patient care and document clinical events (Ozbolt,
Fruchtnicht & Hayden, 1994).
McCartney, P. (2011). Health information technology.
Standardized nursing language and diabetes in children. MCN: The American
Journal Of Maternal Child Nursing, 36(1), 64.
doi:10.1097/NMC.0b013e3181fbaa89
O'Connor, N., Hameister, A., & Kershaw, T. (2000).
Application of standardized nursing language to describe adult nurse
practitioner practice. Nursing Diagnosis, 11(3), 109-120.
Ozbolt, J. G., Fruchtnicht, J. N., & Hayden, J. R.
(1994). Toward data standards for clinical nursing information. Journal Of
The American Medical Informatics Association: JAMIA, 1(2), 175-185.
Rutherford, M., (Jan. 31, 2008) "Standardized
Nursing Language: What Does It Mean for Nursing Practice? "OJIN: The
Online Journal of Issues in Nursing. Vol. 13 No. 1.
