The ANA defines nursing informatics as the specialty that integrates nursing science with information and analytical sciences to identify, define, manage, and communicate data, information, knowledge, and wisdom in nursing practice. It is a nursing specialty with its own ANA scope and standards; informatics nurses often lead system design, training, and optimization.

The data–information–knowledge–wisdom (DIKW) continuum

Key systems

Interoperability is the ability of different systems to exchange data and use the exchanged data meaningfully (for example, a home health agency receiving a hospital's discharge medication list in a usable form). It depends on standards for message format (e.g., HL7 FHIR) and on standardized terminologies so that a term means the same thing everywhere.

Standardized nursing terminologies make nursing care visible, comparable, and measurable across settings and allow data to be used for quality measurement and research. ANA-recognized examples include NANDA International (diagnoses), Nursing Interventions Classification (NIC), Nursing Outcomes Classification (NOC), the Omaha System (widely used in community and home health), the Clinical Care Classification (CCC), the Perioperative Nursing Data Set, the International Classification for Nursing Practice (ICNP), SNOMED CT, and LOINC (lab and assessment observations). Linking a diagnosis to its interventions and outcomes in the EHR (NANDA-I → NIC → NOC) supports a computerized nursing process.

US policy milestones

• HIPAA (1996) — Privacy Rule (who may use and disclose protected health information, minimum necessary standard, client right to access and request amendment), Security Rule (administrative, physical, and technical safeguards for electronic data), Breach Notification Rule
• HITECH Act (2009) — funded EHR adoption through "meaningful use" incentives (now CMS Promoting Interoperability) and strengthened HIPAA enforcement
• 21st Century Cures Act (2016) — prohibits information blocking and supports clients' electronic access to their health information, including many clinical notes

Principles of documentation (applies to paper and electronic records; consistent with FN-026)

• Accurate and objective — record what was observed, measured, or said (quote the client); avoid judgmental or vague terms ("appears upset," "good day"). Write "states pain 7/10 in right hip; grimacing; guarding" rather than "seems to be in a lot of pain"
• Timely — document as soon as possible after care; never before it is done. Late entries are labeled "late entry" with the current date and time and the time the event occurred
• Complete and concise — assessments, interventions, the client's response, teaching and evidence of understanding, and notifications (who, when, what was said, what orders were received)
• Legible, permanent, signed with credentials; use only approved abbreviations (avoid The Joint Commission "Do Not Use" list)
• Corrections: in the EHR, follow the amendment process, which keeps the original visible in the audit trail; on paper, draw a single line through the error so it remains readable, write "error" or "mistaken entry" with date, time, and initials, then add the correct entry. Never erase, obliterate, use correction fluid, or delete
• Only document your own care; never chart for another nurse
• Do not mention incident reports in the chart (see Topic 27)

Documentation formats

Communication tools: SBAR (Situation, Background, Assessment, Recommendation) for reporting a change in condition — state who you are, the client, and the problem first; I-PASS or bedside handoff for shift report; read-back for verbal and telephone orders and critical results.

Using the EHR safely

• Scan every client band and medication; if a scan fails, find and fix the cause rather than overriding by habit
• Read alerts before overriding; document the reason for any override. Alert fatigue (too many low-value alerts) is a system problem to report to informatics, not a reason to ignore alerts
• Avoid copy-and-paste or "copy forward" of previous assessments without re-verifying — it spreads outdated or false information and is a legal risk
• Check that the right client's chart is open before entering data (wrong-chart errors)
• Know downtime procedures (paper forms, backup medication records) and how to enter downtime data later
• Log off or lock the screen when leaving a workstation; never share passwords

Telehealth and remote care: confirm client identity and location, protect privacy during video visits, document the same as in person, and follow licensure rules — a nurse must be licensed in the state where the client is located (a multistate license under the Nurse Licensure Compact covers member states).

Artificial intelligence and ambient documentation tools are entering practice. The nurse remains accountable for everything documented under their name: review and correct any AI-generated text, and report inaccurate or biased outputs.

Data for improvement and research: aggregated EHR data (sometimes called big data) support early-warning systems, prediction of falls or sepsis, staffing decisions, and quality measurement. Accurate, structured nursing documentation is what makes these uses possible.

• Document accurately and promptly; the chart is a legal record and a communication tool
• Protect privacy and security: access only the records needed for your role; auditing tracks every access
• Participate in system selection, testing, and training as a super-user when possible — frontline nurses must be involved from planning through evaluation
• Report usability problems, unsafe workarounds, and alert fatigue
• Teach clients to use portals safely and to review their records
• Managers: ensure training and competence before go-live, support staff through implementation (a change-management process), and monitor documentation quality

• The medical record is a legal document: it is evidence of the care given. In court, "not documented" is often treated as "not done." Timely, factual entries protect both client and nurse
• HIPAA: disclose only the minimum necessary information; clients may access their record and request amendments; breaches must be reported under the facility's policy. Looking up a relative, coworker, or celebrity without a work reason is a violation that can lead to termination and board discipline
• Social media: never post client information or images, even without names; details can identify a client. Follow NCSBN and employer social media guidance
• Information blocking is prohibited under the Cures Act; clients generally have a right to timely electronic access
• Tampering with records (altering, backdating, deleting) is illegal and grounds for license discipline
• Ethics: the ANA Code of Ethics requires protecting the client's privacy and confidentiality in all forms of communication

Case 1 — Correction. A nurse realizes she documented a dressing change in the wrong client's electronic chart. She uses the EHR's "entered in error" function per policy, adds a note explaining the correction, documents in the correct chart, and notifies the charge nurse. Why: the original entry remains in the audit trail; deleting or hiding it would be tampering.

Case 2 — Objective charting. A student writes "client is uncooperative." The instructor asks her to record what happened: "Client refused 0900 metoprolol, stating 'It makes me dizzy.' Provider notified at 0910." Why: objective, specific facts and quotes are clear and defensible.

Case 3 — BCMA override. The scanner rejects a medication because the dose differs from the order. Instead of overriding, the nurse checks the order and contacts the pharmacy, who find a transcription error. Why: BCMA alerts catch wrong-drug and wrong-dose errors only if nurses respond to them.

Case 4 — SBAR. A client's oxygen saturation drops to 86% on 2 L. After raising the head of the bed and titrating oxygen per protocol while staying with the client, the nurse calls the provider: "This is Maria, RN on 5 West, calling about Mr. Lee in room 12. His SpO₂ dropped to 86% on 2 liters over the past hour..." Why: stating the situation first gives the listener the key problem immediately.

• Erasing or blacking out an error, or deleting an EHR entry instead of amending it
• Documenting care before it is given
• Using subjective labels instead of observed facts and quotes
• Treating BCMA as mainly preventing wrong-time errors — it chiefly prevents wrong-client, wrong-drug, and wrong-dose errors
• Believing interoperability means only connecting computers — the data must also be understandable and usable (semantic interoperability)
• Accessing a record out of curiosity "just to check"
• Copying forward previous assessments without re-assessing
• Assuming the Kardex is the permanent legal record

• DIKW: data → information → knowledge → wisdom
• Interoperability = exchange and meaningful use of data; needs standard terminologies (NANDA-I, NIC, NOC, Omaha, SNOMED CT, LOINC)
• BCMA prevents wrong-client, wrong-drug, and wrong-dose errors; CPOE removes illegible orders; CDS gives alerts and order sets
• Documentation: accurate, objective, timely, complete, signed; never chart ahead
• Paper correction: single line, "error"/"mistaken entry," date, time, initials; EHR: amendment process; never erase or delete
• Late entry labeled with current time and time of event
• SOAP(IER), PIE, DAR, charting by exception; flow sheets graph trends such as intake and output
• SBAR for changes in condition; read back verbal and critical-result communication
• HIPAA: minimum necessary, access only for work; Cures Act bans information blocking
• The record is a legal document — "not documented, not done"