Profiles in Nursing
Marjorie Gordon and the Electronic Medical Record
Data management beyond charting in colored ink for different shifts
AS HOSPITALS MOVE TOWARD ELECTRONIC RECORDS, nurses are probably recognizing that old favorites like “appears to be sleeping” or “breathing comfortably” just don’t cut it anymore. Each patient presents a much more complicated picture, and each requires a more succinct and accurate assessment.
Furthermore, it is increasingly critical to capture and record exactly what the nurse is doing. Acuity measurements depend on it, and so do reimbursements. Today’s medical chart is a whole new animal, because the analysis of data requires the ability to computer code the material. We are talking about something way beyond using green ink to designate the evening shift, red for the night shift and blue for the day shift. Fortunately for our profession, some of us have been thinking hard about these issues for quite some time.
Marjory Gordon is one such nurse. So great is her influence that on her nomination as a “living legend” of the American Academy of Nursing, fellow legend Sister Callista Roy said, “She caught an idea…. She began this work when computers were just starting. And, now this is the basis for [the nursing component of] the electronic medical record.”
Gordon’s interest really started as a fluke. With a concentration on adult medical-surgical nursing, she had aimed to focus her doctoral work on her long-time interest, neurophysiology. But when graduate studies in that field appeared more complex than their actual usefulness, she concentrated instead on cognitive psychology. Her interest in clinical reasoning and judgment led her to attend the first nursing conference on nursing diagnosis sponsored by faculty at St. Louis University. It proved a pivotal event, because out of that meeting in 1972 came, 10 years later, the North American Nursing Diagnosis Association. Gordon served as its first president; in another quirk of fate, she took on a second term when, as she says, “no one else would run for the office.”
NANDA International, with 50 percent of its membership non-North American, has grown over the years. It bases its language of nursing diagnosis not on an alphabetical system, but rather on a classification system organized across several realms. What started out as 25 nursing diagnoses has grown, in time, to 206 over 13 domains. Standardized nursing language has enormous implications for research, education, evaluation of competency and the establishment of a core of nursing knowledge based on evidence.
Gordon has another area of renown, and that is as the theorist behind Functional Health Patterns. This widely used system of nursing assessment, unlike the medical model so familiar in the past, captures the holistic nature of each patient, including the physical, spiritual, emotional and social. It is closely aligned with the NANDA taxonomy.
Gordon has published four books, including the Manual of Nursing Diagnosis, in its 12th edition and available in 10 different languages. Her texts are used on “nearly every continent,” she said.
Now Professor Emerita at Boston College, where she spent 23 years on the faculty of the Cornell School of Nursing, she is currently working on a book about clinical reasoning. “It is critical that nurses are taught the thinking skills and cognitive reasoning that can help them translate their observations into clinical judgments.”
Makes sense, doesn’t it? As Gordon reminds us, “Knowledge in health care can change over the course of a few years, but cognitive abilities last for a lifetime.”
Elizabeth Hanink, RN, BSN, PHN is a freelance writer with extensive hospital and community-based nursing experience.
This article is from workingnurse.com.