Representing nursing judgements in the electronic health record Anne Moen RN MNSc Doctoral Student, Institute of Nursing Science, Faculty of Medicine, University of Oslo, Oslo, Norway and School of Nursing, University of California, San Francisco, California, USA Suzanne Bakken Henry RN DNSc Associate Professor, School of Nursing, University of California, San Francisco, California, USA and Judith J. Warren RN PhD Associate Professor and Clinical Nurse Researcher, University Hospital and College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska, USA Accepted for publication 8 January 1999 MOEN MOEN A., BAKKEN BAKKEN HENRY S. HENRY S. & WARREN J WARREN J.J. (1999) J. (1999) Journal of Advanced Nursing 30(4), 990±997 Representing nursing judgements in the electronic health record The naming of nursing phenomena and representing the phenomena in a standardized manner suitable for encoding in computer-based systems is a challenge for the nursing profession at the national and the international level. Considerable progress has been made in the development of classi®cation systems for nursing practice. The focus of this article is on language systems developed to represent nursing judgements in computer-based systems, in particular the electronic health record. A review of two current systems and their proposed revisions (North American Nursing Diagnosis Association, NANDA, Taxonomies I and II, and the International Classi®cation for Nursing Practice, ICNP, Alpha and Beta versions), according to the features suggested by the Computer-based Patient Record Institute (CPRI) for classi®cation systems appropriate for implementation in computer-based systems, suggests that the evolving versions extend the current versions in terms of suf®cient granularity (depth and level of detail) and atomic and compositional character. However, it is not clear from the literature available to date whether the characteristics that are most closely related to de®nition of a formal terminology (i.e. clear and non- redundant representation of concepts, syntax and grammar for logical constructions of compositional terms, synonyms and language independence) will be part of the evolving vocabularies. Formal terminology models and related tools have the potential to complement, extend, and re®ne existing nursing classi®cation systems. Correspondence: Anne Moen, PO Box 1120, Blindern N-0317 Oslo, Norway. E-mail: anne.moen@sykepleievit.uio.no Journal of Advanced Nursing, 1999, 30(4), 990±997 Methodological issues in nursing research 990 Ó 1999 Blackwell Science Ltd